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Student Complaint Form

Complainant Personal Information

First Name

*

Last Name

*

Email

*

Phone

*

Address

*

Additional Address

City

*

State

*

Zip Code

*

Incident Description

Type of complaint

Distance Education
Regular Complaint

*

I have a complaint against

*

This person is a

Student
Faculty Member
Staff Member

*

Department

If Applicable

Date of incident

*

Approximate time of incident

*

Please describe the incident

*

Witness Information

Witness 1 Name

Witness 1 Phone

Witness 1 Email

Witness 2 Name

Witness 2 Phone

Witness 2 Email

Other Important Information