SA3 (Student Government) Concern/Suggestion Form 1 This Form is

SA3 (Student Government)
Concern/Suggestion Form
This Form is not to be used for Grade Appeals
Any student expressing a concern or suggestion, positive or negative is encouraged to submit this form. This completed form should
be submitted to the SA3 President; or may be received, dated and signed by the Student Life Office, Student Development
Coordinator.
Please identify the nature of the Concern/Suggestion
Academic Concern/Suggestion.
Non-Academic Concern/Suggestion
Behavioral Concern
Name
Day Phone #
This concerns the following campus/site:
Student ID
Date
Evening Phone #
AH
HL
OR
RO
SF
Other
Description of the concern/suggestion or incident. If a specific person is involved, please include their name.
Please explain the level of your concern (threatened, uncomfortable, harassed, etc.):
If your concern involves a particular class or department, please complete below:
Course code:
Department:
1
Section Number:
Instructor:
SA3 (Student Government)
Concern/Suggestion Form
Have you met with the instructor involved?
Have you met with the Department Chair:
Yes
Yes
No
No
NA
NA
Actions/ Recommendations:
Date
X
Student Development Coordinator
X
SA 3 President
Information recorded in the SA3 Data Base
2
Date:
By: