Student Complaint Form

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Student Complaint Form
Student's Name*
First Name Last Name
Student's Email*
Date submitted*
Month Day Year
Description of Complaint
Date of incident:*
Month Day Year
Time of incident:
Location:
Witnesses:
Is alleged offender?

Student Administrator Faculty Member Support Staff Other
Circumstances (events leading up to incident, actions taken, follow-up, etc.):
Remedy Requested
I hereby declare that the informatioin on this form is true, correct and complete to the best of my knowledge. I understand that any misinterpretation of information may result in disciplinary action as stipulated in the Code of Student Rights and Standards of Conduct.*
Other Evidence for upload:
Should be Empty:

Description of Complaint