FORM FOR REQUESTING A GRADE CHANGE This form is to be

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.