Student Complaint Report Form

Background Information (Required)

Enable additional features by logging in.

Your full name (Required):

Your student ID # (Required):

Your phone number (Required):

Your PCC email (Required):

Email address must be of a valid format.

Your address (Required):

Nature of the complaint(Required):

This field is required.

Date of the incident(Required):

This field is required.

Time of incident (Required):

Location of the incident(Required):

This field is required.

Specific location (Required):

Learn more

Room number, course number and section. (if applicable)

Involved Parties (Required)

Identify the individual(s) involved in this complaint. Please include as much of the requested information to the best of your knowledge. It is understood that not all information will be submitted in this report.

Name

Gender

Role

Student ID Number

Job Title (if faculty or staff)

Phone number

PCC email address

Address (if applicable)

Questions (Required)

Please answer each question to the best of your knowledge.

Can you please provide a detailed description, using factual information only, of the incident using specific concise, objective language (who, what, where, when, why, and how)? Please include a timeline of events leading up to the incident, if possible.(Required) This field is required.

Have you fulfilled Step 1 of the Student Complaint Procedure? If the answer is yes, proceed to the next question. If the answer is no, please take the necessary steps to fulfill Step 1.(Required)

Yes No

You must make at least one selection.

Have you fulfilled Step 2 of the Student Complaint Procedure? If the answer is yes, proceed to the next question. If the answer is no, please take the necessary steps to fulfill Step 2.

Yes

You must make at least one selection.

If you answered yes to the previous two questions, please share what you did in an effort to try to resolve the matter? What was the outcome?(Required) This field is required.

Can you please describe how you would expect the complaint to be resolved? Specific actions or suggestions for resolving this issue is highly encouraged. Please be as specific as possible.(Required) This field is required.

Supporting Documentation (Required)

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 (Required)

Involved Parties (Required)

Questions (Required)

Supporting Documentation (Required)

Submission