Complaint Form
The following form is to be used in the Complaint Process for Students as noted in the College catalog under College
Regulations and Policies. The student and staff/faculty member involved in the complaint should try to resolve the
dispute through discussion. If resolution is not reached at this level, the student must complete this “Complaint
Form” and submit it to the staff/faculty member’s immediate supervisor within five (5) working days of the alleged
complaint. This written documentation allows for a more formal and consistent review of the particular situation.
Student Name: ________________________________________________________________________________________
Student ID#: __________________________________________________________________________________________
Phone No.: ___________________________________________________________________________________________
Email Address: _________________________________________________________________________________________
Summary of Complaint:
(please note details, dates if applicable, sequence of events, etc.; use additional paper if necessary)
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Desired Outcome:
(please note what specific results you would like to see achieved through this process)
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Student Signature
__________________________________________________________________Date ________________
Complete and return this form to and schedule a meeting with the immediate supervisor of the staff/faculty member with whom you
have the complaint. Note: a supervisor may be a coordinator, department chair, director, dean, or vice president.
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