Method of Contact: Office Visit Telephone Call E-mail Letter Fax

PLEASE PRINT CLEARLY DATE:__________________________

STUDENT’S NAME_________________________________________ ID# or SSN__________________

PHONE____________________ LOCAL ADDRESS__________________________________________________

E-MAIL______________________________________________________________________________________

CLASSIFICATION: FR SOPH JR SR GRAD alum LEAD Last Semester Enrolled at Fisk_____________

MAJOR(S)___________________________________ ADVISOR(S)_____________________________________

OTHER PERSON MAKING COMPLAINT___________________________________ PHONE____________________

RELATIONSHIP TO STUDENT_____________________ REFERRED BY____________________________________

Please Describe Your Complaint

(you may continue on the back of this form)

_____________________________________________________________________________________________

Not Approved

DATE(S) MISSED_____________________ RATIONALE (supporting documentation required)_________________

INSTRUCTOR(S) TO BE NOTIFIED____________________________________________________________________

Date/Time: 1st________________________ 2nd________________________ 3^rd__________________________

REFERRED TO: _______________________________________________________________________________

Immediate Action Taken by AESP

(please continue on the back of this form)

Student’s Academic Status____________ Sem GPA____ Sem Hrs___ Cum GPA____ Cum Hrs___ #Sem at Fisk____

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Additional Comment(s) of Student or Other Person Making Complaint

(continued from front)

_____________________________________________________________________________________________

Student’s Signature & Date (optional)_____________________________________________________________

Follow-up Action Taken by AESP

(continued from front)

_____________________________________________________________________________________________

Email 1 To whom ______________________________________________ Date_________________

Response _____________________________________________________________________

_____________________________________________________________________

Phone Call 1 To whom ______________________________________________ Date_________________

Response ______________________________________________________________________

______________________________________________________________________

Email 2 To whom ______________________________________________ Date__________________

Response ______________________________________________________________________

______________________________________________________________________

Phone Call 2 To whom ______________________________________________ Date_________________

Response _____________________________________________________________________

______________________________________________________________________

Final Resolution

(please include the date)

____________________________________________________________________________________________

AESP rev 7/27/2011 aa