Student Complaint Form - Alabama Community College System

Full Name*

First Last

A#*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email*

Institution Name*

Last Date of Attendance

Semester of Incident*

Year of Incident*

Location of Incident

Did you follow the Institution's grievance procedure to resolve your complaint?

No
Yes

If no, stop here and refer back to the institution's complaint/grievance process. Please exhaust all steps in the institution's complaint/grievance process before filling a complain with the System Office of the Alabama Community College System.

Phone Call Checkbox

Phone Call

Who did you contact?

Date of Contact

In Person Checkbox

In Person

Who did you contact?

Date of Contact

Letter Checkbox

Letter

Who did you contact?

Date of Contact

Email Checkbox

Email

Who did you contact?

Date of Contact

Other Checkbox

Other

What method of contact did you use?

Who did you contact?

Date of Contact

What outcome did you seek from the Institution?*

Have you contacted another agency or organization about the matter?

Yes
No

Please give name of agency.

Have you contacted an attorney?

Yes
No

Please give name of attorney.

Describe your complaint in detail. Specify any dates, staff you dealt with, monies owed, balances due, etc.*

Upload any documentation below which will help describe the problem and substantiate your allegations, such as an enrollment contract, correspondence with or from the institution, etc.

What outcome are you seeking from ACCS?*

Please upload supportive documentation if applicable (by way of example, emails, recordings, syllabus)

Drop files here or

Max. file size: 128 MB.

I certify that the above information is true and correct to the best of my knowledge and grant the ACCS permission to release my name and complaint details to the System Office investigation officer and the institution for response.

Signature of Complainant

Date

Consent to Release Student Information

I hereby consent to the institution's release of any of my educational records, including personally identifiable information that the institution determines is relevant and necessary to provide to the ACCS System Office in response to my complain. I also authorize representatives of the institution to discuss the details of my complain with representatives of the ACCS System Office.

Signature

Date

A#