Student Problem Resolution Form

Background Information

Student’s may also email the Student Conduct Coordinator studentconductcoordinator@palmbeachstate.edu or call (561) 868-3319 for assistance with filing the complaint.

Please include as many details as possible including name and contact information. Please note that submitting the report anonymously may significantly limit the institution’s ability to address your concern.

Your email address:

Email address must be of a valid format.

Nature of this complaint(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Select a campus(Required):

This field is required.

Specific location:

Learn more

Ex. Building Number or Course ID

Involved Parties

Please identify yourself and all individuals involved. Complete as many of the listed fields as you can provide.

Name

Select Role

Student ID Number (S12251203) Do not use dashes

Phone number

Email address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Please describe the steps you have taken to try to resolve this issue before filing this formal complaint?(Required) This field is required.

Have you already interacted with an office about this issue or concern?(Required)

Yes No

This field is required.

If you answered "Yes" to the above, which office(s) have you contacted? Please provide the name of the person(s) that you have been working with. If you answered "No", please explain why.(Required) This field is required.

What type of resolution are you seeking?(Required) This field is required.

I certify that this information is correct to the best of my knowledge.(Required)

Yes No

This field is required.

Supporting Documentation

Please include any written documentation related to this issue (emails, college forms, etc.) 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission