CLC Student Concern Form

CLC Student Concern Form
Name ________________________________________________________________________ Last First Middle Tech ID# Address ______________________________________________________________________ ______________________________________________________________________________ City State Zip Telephone #: ____________________ Cell#: ______________________ TYPE OF CONCERN:  Academic (Academic Integrity, Academic Suspension, Courses, Grades, Faculty, Programs)  Service (ADA, Data Privacy, Disability Services, General Concern, Technology)  Behavior and Student Conduct (Discrimination, Harassment, Student Conduct) 1. First attempt to resolve any concern(s) you have with the person (office) with whom you have the concern. 2. If you are not satisfied, speak to a counselor in the Counseling Department. The counselor will listen and help you identify alternative solutions. 3. If upon meeting with a counselor, you determine you would like to file a formal complaint, complete this form. 4. 5. 6. 7. Describe specific incident/concern (list dates, times, events): Attach additional pages as needed. Describe how you believe the situation can be resolved: Attach any documents that support your concern, if appropriate. Identify time(s) when you are available to meet (day, date, time): ___________________________ Please return this form to: Trudy Austin, Brainerd, or Jody Longbella, Staples Academic Affairs Office located on the 2nd floor administrative suite on both campuses CLC is committed to a policy of nondiscrimination in employment and education opportunity. No person shall be discriminated against in the terms and conditions of employment, personnel practices, or access to and participation in, programs, services, and activities with regard to race, sex, color, creed, religion, age, national origin, disability, marital status, status with regard to public assistance, sexual orientation, or membership or activity in a local commission as defined by law. This information is available in alternative format upon a 48-­‐hour advance request by contacting Paula Huss in Disability Services, office C111 at 800-­‐933-­‐0346 ext 8175. Deaf and Hard of Hearing users or TTY communication contact the "Minnesota Relay Service at 7-­‐1-­‐1 or 1-­‐
800-­‐627-­‐3529.”
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