Student Grievance Form

This form is to be used by students requesting a formal hearing as outlined in the Student Complaint and Grievance Procedures. This form, when completed, will be submitted to the Office of Student Services, Blake Center. Information and assistance in completing the grievance statement below may be obtained from the Office of Student Services.

For a full definition, please review the university’s published student grievance policies and procedures in the student's handbook.

COMPLAINANT INFO

STUDENT ID#

STUDENT'S LAST NAME

STUDENT'S FIRST NAME

ADDRESS

TELEPHONE

EMAIL ADDRESS

GRIEVANCE AGAINST THE GRADE/ACTION OF (please check)

GRADE

FACULTY MEMBER

STAFF

OTHER

IF OTHER, PLEASE EXPLAIN:

PERSON WHO DISCRIMINATED AGAINST YOU:

Is this grievance based on unlawful discrimination, harassment or retaliation?

Yes. (if Yes, Please use Title IX Form: Visit: https://www2.oakwood.edu/title-ix/

Is this a grade grievance? If yes, complete the following information:

Course/ Term/Year / Grade Received

FACULTY NAME

TITLE

DEPARTMENT

IF NOT GRADE GRIEVANCE- Description of Complaint:

If this is not a grade grievance, briefly state your complaint.

COMPLAINT

PREVIOUS ACTION:

Have you brought this matter to the attention of any other department(s) at the university? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter.

PREVIOUS ACTION

Complaint Documentation:

Explain any documentation supporting your complaint.

DOCUMENTATION:

Corrective Action Sought:

Describe the corrective action you are seeking.

CORRECTIVE ACTION SOUGHT:

Witnesses:

(Relationship=co-worker, supervisor, classmate, faculty, etc.)

Name

Name

Name

Title/Relationship

Title/Relationship

Title/Relationship

Phone Number

Phone Number

Phone Number

I declare under penalty or perjury that the information provided is true.

I declare under penalty or perjury that the information provided is true.

Student Grievance Form

Student Grievance Form

COMPLAINANT INFO

GRIEVANCE AGAINST THE GRADE/ACTION OF (please check)

PERSON WHO DISCRIMINATED AGAINST YOU:

IF NOT GRADE GRIEVANCE- Description of Complaint:

PREVIOUS ACTION:

Complaint Documentation:

Corrective Action Sought:

Witnesses:

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