Distance Education Grievance/Complaint Form

First Name

Middle Name

Last Name

Email Address

Phone Number

How do you prefer to be contacted?

Email

Phone

Mailing Address

Country

Street

City

Region

Postal Code

Date of Incident

Location of Incident:

What category best describes your academic level status?

Graduate: pursuing a Masters Degree

Undergraduate: pursuing a Bachelor's Degree

Professional Development: not pursuing a degree

Other

What was your student status at the time of the incident?

Student

On Leave

Alum

Other

Please describe your complaint/inquiry in detail. Include all relevant names and other pertinent information. Provide details below in the clearest possible language. Indicate how the division, department, or individual has violated an established policy or procedure.(Required)

Please give titles and contact information for the individuals (if any) that were involved or may have knowledge about the incident.

Do you have additional documentation to submit in reference to this incident (including emails, photos, videos, course syllabi, transcripts, tuition bills, etc.)?

Yes

No

If you answered yes to the previous question, then please tell us what additional information you would like to submit.

Describe any action you have taken to resolve this matter and how the division, department or individual has responded to you. Describe the steps taken to pursue any other existing grievance or appeals process. Describe the actions of the relevant individuals to date. You may be asked to provide a copy of any official written responses received as a result of those prescribed procedures. (Required)

How would you like your complaint to be addressed? (Required)

Certification: I have reviewed the appropriate policies and procedures that are germane to this grievance or complaint, including but not limited to: the Student Handbook, Faculty Legislation, the Staff Handbook, or other Institutional Policies. I understand that if this grievance or complaint is covered by any other existing grievance or appeal policy, I will be asked to follow the appropriate procedure. I hereby certify that all of the information I have given in this official written grievance or complaint is accurate and complete to the best of my knowledge. (Required)

Thank you for submitting this form. We will be in contact with you to follow up. Please be ready to share any related supporting documents (including photos, video, email, or other documents) related to your complaint/grievance.

Distance Education Grievance/Complaint Form

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