Student Grievance Form - Virginia Western Community College

Student Grievance Form
(To be completed by student)
Name of Student
Date
Student’s EMPLid #
Student’s Telephone #
Semester/Year
Class (if applicable)
Before completing this form, every effort should be made to resolve the issue with the employee informally. If, after
meeting informally with the employee, you are not satisfied with the outcome, please follow the steps outlined
below.
Grievance: (Check any that apply)
Issue with Instructor or Staff Member
(academic or nonacademic issue)
Grade Dispute (academic issue)
Final Grade Appeal (academic issue)
Issue with a College Procedure (academic
or nonacademic issue)
Issue with Class (academic or nonacademic
issue)
Step A: Please provide a description of your grievance in Box I on the back of this form.
Step B: You must schedule a meeting with the instructor or staff member involved and have that person fill out
Box II on the back of this form.
Step C: For issues that are not resolved by meeting with the instructor or staff member (Completion of Step B),
schedule a meeting with the program head and/or supervisor for that department. Following the meeting, the
program head or supervisor will complete Box III and notify the student of the grievance decision. If your instructor is
the program head, or if the staff member is the department supervisor, skip to Step D.
_________________________
Program Head or Supervisor’s Signature
____________
Date
*Have student initial here if the issue has been
satisfactorily resolved ___________
Step D: If you are not satisfied with the result of the grievance process at Step C, schedule a meeting with the
appropriate dean. If there is no dean for that area, skip to Step E. Following the meeting, the dean will complete Box
IV and notify the student of the grievance decision.
______________________________________
Dean’s Signature
_________________
Date
*Have student initial here if the issue has been
satisfactorily resolved ___________
Step E: If you are still not satisfied with the outcome of the grievance after completing the steps outlined above,
you may appeal to the appropriate Vice President following Step D of the Student Grievance Policy. You must appeal
the result within five business days of the date listed in the last step completed above. The decision of the Vice
President is final. The Vice President will complete Box V and notify the student of the grievance decision.
Over
Box I: Student - Place short description of grievance here:
Attachments with _____ pages
______________________________________________
Student’s Signature/Date
Box II: Instructor/Staff - Explain results of meeting with student here:
Attachments with _____ pages
_________________________________________
Instructor/Staff’s Signature/Date
Box III: Program Head/Supervisor - Explain results of meeting with student and faculty here:
Attachments with _____ pages
______________________________________________
Program Head/Supervisor’s Signature/Date
Box IV: Dean - Explain results of meeting with student, faculty, and/or program head here:
Attachments with _____ pages
______________________________________________
Dean’s Signature/Date
Box V: Vice President - Explain results of meeting with student, faculty, and program head, and/or dean
here: Attachments with _____ pages
______________________________________________
Vice President’s Signature/Date
Revised 8-4-15