Student Affairs Office: SS‐204 Phone: (562) 908‐3498 Statement of Grievance Name: _________ ________________________________________ Date: _______________ Last First Student ID #: _________________ Phone: _________________ E‐mail: ____________________ Please check one: □ Academic Grievance □ Non‐Academic Grievance If Academic, check the category(s) that apply (must have supporting documentation): □ Mistake □ Fraud □ Bad Faith □ Incompetency If Non‐Academic, specify: ________________________ Date of the incident on which the grievance is based or date that you learned of the basis for the grievance (whichever is later): _________ Person(s) charged:_______________________________________________ Attach additional documentation if needed Clearly specify your grievance:_____ ___ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________
Requested outcome (specify the solution/action you want taken): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Steps you have taken to attempt to resolve the grievance: _____________________ Student Signature ________ ________ Date ____________