PLATTSBURGH STATE UNIVERSITY OF NEW YORK
GRADE IRREGULARITY FORM
Directions: This form is to be used by an instructor to change a student's grade or to submit a grade for a student
whose name does not appear on the grade roster. In either case, the instructor completes this form and returns it to
his/her Departmental Chairperson.
STUDENT'S NAME
Course #
SOCIAL SECURITY NUMBER
Section
Course Title
Credits
This course was initiated during the
Instructor
of
semester
Year
Complete either 1 or 21. Change grade from
to
Date student completed work)
/
Effective
/
Please note: The date student completed work can determine the graduation date. Please make sure this date is
the actual date of completion and not the date the form is being completed.
Reason:
2. Give this grade of
because student's name was not on grade roster.
Instructor's Signature and Date
Chairperson's Signature and Date
Dean's Signature and Date