Student Complaint Report Form

Background Information

Your full name:

S#::

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Specific location:

Involved Parties

Please list all individuals involved including yourself in the actual incident or concern. For non-students, please list an SSN or Drivers License number in the block labeled SID (Student ID #) if available.

Name or Organization

ID Number

Phone number

Email address

Brief Description of Concern or Complaint:

Please describe in detail of your concern or complaint.(Required) This field is required.

Have you spoken with a college department or individual with regards to this concern or complaint?(Required)

Yes No

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 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

Brief Description of Concern or Complaint:

Supporting Documentation

Submission