Student's Description of Problem

Form Purpose: To be used for issues not covered by other policies.

Please Note: Complaint submissions must be made within 10 business days of the event giving rise to the complaint. Be prepared to provide additional documentation, if applicable.

Instructions: Please fill out all of the required fields in the form and press the "Submit" button. To submit anonymously, just type "Anonymous" in the name and any other sections that might identify you. Please retain a copy of this complaint for your records. A confirmation e-mail will be sent to the e-mail specified unless submitted anonymously.

*Required Field

Your Name: Your Name: First Middle Last
Tech ID#:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Tech Student Email:
Home Phone: Home Phone: - ### - ### ####
Mobile Phone: Mobile Phone: - ### - ### ####
Date of Alleged Conflict or Action: Date of Alleged Conflict or Action: / MM / DD YYYY
Name of Department or office in which problem occurred:
List other person(s) who may provide information:
Summary of Your Complaint:
Maximum of 250 characters allowed. Currently Entered: 0 characters.
Describe efforts you have made to resolve this matter:
Maximum of 250 characters allowed. Currently Entered: 0 characters.
What do you think would be a fair resolution to this issue?:
Maximum of 250 characters allowed. Currently Entered: 0 characters.
Type the letters you see in the image below.