Student Complaint Form

The student complaint procedure was developed to deal with issues between students and employees at LSUA, including faculty and staff. The student complaint policy defines a formal procedure for addressing matters that have not been resolved through informal resolution. Students seeking redress of grievances may do so without fear of retaliation.

Name of person filing report

Phone Number

(xxx) xxx-xxxx

Department of Issue

Professor/Staff Name

Class the issue is about (if applicable)

Date of Issue

Narrative about the complaint and include timeline with dates, times, location, and names of others who may be involved. Please include a summary of interactions with those who have been involved so far.

Action requested by the student to rectify the complaint.

Supporting documentation (ability to upload documents/photos):

Add another

Check Agree/Acknowledge that the student has met with the faculty member and department chair and attempted an informal resolution for academic grievance or met with the staff directly for a staff grievance.

Agree/Acknowledge

What was the date of the meeting with the Faculty/Department Chair/Staff Member?

By typing my full name below in the signature field, I agree that this form is as valid as if I signed the form in writing.