Student Complaint/Grievance Reporting Form

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Rogers State University

Student Complaint/Grievances Reporting From

Background Information

Nature of Report:

Urgency of Report:

Date of Incident:

Time of Incident:

Specific Location:

Please Note:

For additional information on Residence Hall Violations, see Residence Life Handbook.
All student complaints/grievances related to Academics will be processed through the Vice President for Academic Affairs Office. If the issue is regarding academic integrity or appealing a grade, you can find more information in the Academic Policies and Procedures beginning in Section 4.2; see Academic Policies and Procedures Manual.

Areas on Conduct Violation Report:

Not listed but in Code of Conduct:

Failure to comply with the direction of University officials
Failure to keep records up to date (ex. Address in Registrar)
Interfering or interrupting with fire/police responses
Unauthorized entry or exit or attempting to enter or exit
Violation of local, state, federal law, or university policy

In the space below explain in chronological order the nature of your complaint with as much detail as possible. For example, list persons involved, date(s) and time(s).

Involved Parties

Incident Details: Please provide a description of the incident with as much detail as possible (Who, what, where, when, why, and how).

First Person Involved

Name or Organization:

Gender:

Role:

ID Number:

Date of Birth:

Phone:

Email:

Hall/Address:

Second Person Involved

Name or Organization:

Gender:

Role:

ID Number:

Date of Birth:

Phone:

Email:

Hall/Address:

Third Person Involved

Name or Organization:

Gender:

Role:

ID Number:

Date of Birth:

Phone:

Email:

Hall/Address:

Did police respond?

Did fire resond?

Did EMS respond?

Outcome

Is there a particular outcome you are seeking? If so, what is it? Please keep in mind that the outcome you are suggesting is not guaranteed. The goal of the Student Affairs office is to engage in fact-finding regarding your complaint/grievance, communicate your concerns to appropriate areas, and to assist in the resolution of any concern.

Please give a brief description of your desired outcome to this situation.

How would you like to receive follow up?

Understand Statement

I understand that some incidents, particularly sexual assault or the intent to do grave bodily injury may be subject to emergency action as authorized by public law. Student Affairs upholds FERPA (privacy rights) in all matters. By providing your contact information, you are also acknowledging that the Vice President for Student Affairs or the Director of Student Conduct and Development will determine what information may be shared as educational need-to-know in the investigation of this complaint. Also, be aware that the information stated in this form may be used in RSU conduct proceedings and/or civil court proceedings.

Optional Information:

Your Full Name:

Today's Date:

Your Phone Number:

Your Email Address:

Your Address:

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