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Student Complaint Form
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Student Complaint Form
Student Complaint Form
Christy Sparks
2020-12-11T11:40:59-06:00
Student Complaint Form
Full Name
*
First
Last
A#
*
Address
*
Street Address
Address Line 2
City
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State
ZIP Code
Phone
*
Alternate Phone
Email
*
Institution Name
*
Bevill State Community College
-Jasper
-Fayette
-Hamilton
-Sumiton
Bishop State Community College
-North Broad Street
-Carver
-Central
-Southwest
Calhoun Community College
-Decatur
-Huntsville / Research Park
Central Alabama Community College
-Alex City
-Childersburg
Chattahoochee Valley Community College
-Phenix City
Coastal Alabama Community College
-Bay Minette
-Thomasville
-Monroeville
-Brewton
-Atmore
-Gulf Shores
-Fairhope
Drake State Community & Technical College
-Huntsville
Enterprise State Community College
-Enterprise
-Alabama Aviation Center
Gadsden State Community College
-Wallace Drive
-East Broad Street Campus
-Valley Street Campus
-Ayers Campus
Ingram State Technical College
-Deatsville
Jefferson State Community College
-Carson Road
-Shelby Campus
-Chilton-Clanton Center
-St. Clair-Pell City Center
Lawson State Community College
-Wilson Road
-Bessemer Campus
Marion Military Institute
-Marion
Northeast Alabama Community College
-Rainsville
Northwest-Shoals Community College
-Muscle Shoals
-Phil Campbell
Reid State Technical College
-Evergreen
Shelton State Community College
-Martin Campus
-Fredd Campus
Snead State Community College
-Boaz
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-Wadley
-Opelika
Trenholm State Community College
-Air Base Blvd
-Patterson Campus
Wallace Community College – Dothan
-Dothan
-Sparks Campus
Wallace State Community College - Hanceville
-Hanceville
Wallace State Community College – Selma
-Selma
Lurleen B. Wallace Community College
-Andalusia
-Greenville Campus
-MacArthur Campus
Last Date of Attendance
MM slash DD slash YYYY
Semester of Incident
*
Fall
Spring
Summer
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
MM slash DD slash YYYY
In Person Checkbox
In Person
Who did you contact?
Date of Contact
MM slash DD slash YYYY
Letter Checkbox
Letter
Who did you contact?
Date of Contact
MM slash DD slash YYYY
Email Checkbox
Email
Who did you contact?
Date of Contact
MM slash DD slash YYYY
Other Checkbox
Other
What method of contact did you use?
Who did you contact?
Date of Contact
MM slash DD slash YYYY
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
Select files
Max. file size: 250 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
Signature of Complainant
Date
MM slash DD slash YYYY
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
Signature
Date
MM slash DD slash YYYY
Date
A#
A#
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