FORM FOR REQUESTING A GRADE CHANGE This form is to be used faculty to request a change of grade for Undergraduate or Graduate students. It is requested that the grade for: __________________________________________________ __________________________________________________ (Student’s Full Name) (Student’s EMPLID Number) In ________________________________________________ (Course Department, Number & Section) Given during the ______________ (Semester) ________________________________________________ (Course Title) ___________ semester, be changed from _________ to __________. (Year) (Original Grade) (New Grade) The reason for this change:____________________________________________________________________________ ______________________________________________________________________________________________________ (Instructor’s Printed Name) □ □ (Instructor’s Signature) (Date) (Associate Dean’s Signature) (Date) The grade change is approved. The grade change is denied. Approval of Associate Dean Comments: (Associate Dean’s Printed Name) ASSOCIATE DEAN: Submit signed form to the Manager of Student Records to complete the grade change.
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