Academic Complaint Form

·         This form is for work-related complaints against a faculty member, such as grade disputes and other disputes of an academic nature.

·         This form should be filled out by the student in the event that the student and the faculty member cannot resolve the issue in question and after a conference with the instructor has occurred.

Civil-rights complaints, such as discrimination or harassment complaints, should be filed with the JCC Legal Affairs office in the Potter Center  Room 211.  The Legal Affairs officer, Diane Fenby, can be reached at 796-8462.

_________________________                    _________________________

Date                                                                                      Course

_________________________                    _________________________
Name of Student (Last name first)                                  Name of Instructor (Last name first)

_____________________________
Address

_____________________________
Phone number (where we may contact you)

Please describe the issue giving rise to your complaint in as much detail as possible. Include any places, dates and/or times you can recall. Attach additional sheets if required, as well as copies of any relevant documents (e.g. a course syllabus).

Please describe as clearly as you can what would resolve this issue in a satisfactory manner, in your opinion. Attach additional sheets if required.

This form must be returned to the Department Chair. The chair will then arrange a meeting with you and the instructor within ten (10) school days of receipt of this completed form.

Date form received by Department Chair: __________________________