Program: BS-ITU___ HP___ FB___ HC___ ASD___ HA___

Date: _____________ Student Name:

Date of incident (if applicable): ______________ Time of Incident (if applicable): _________AM__ PM__

What is your complaint or your grievance? (Please be specific & write or print clearly
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
(Use another sheet if necessary)

Names of Witnesses (if applicable) _____________________________________________________________________________________________
_____________________________________________________________________________________________

Ideas you may have or actions you have taken for improving or resolving the situation, issue, condition or incident:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Person completing this report (check one): Student ___ Staff ___
Print Name ______________________________ Signature __________________________________
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Student Complaint/Grievance Form – Page 2

Received by: _________________________________________________________ Date received___________
(Administrator)
Findings of the Administrator, including improvement / resolution if applicable,
and/or follow ups required (specify who, will do what & when):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(Use another sheet if necessary)
Attach Incident Report if applicable.

Name (print) __________________________Signature __________________________________ Date __________
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Who discussed the findings of the review with the student?

Name (print) __________________________Signature __________________________________ Date __________
The findings of the review of my complaint/grievance were discussed with me.

Student’s name (print) _________________________Signature ______________________________ Date _______
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Copies of all Student Complaint/Grievance forms are to be sent to the Chairperson of the Human Rights & Organizational Ethics Committee for review.
Date the copy of this form was sent to the HROE Chairperson ________/______/_______

Name of the person who sent the form (Print) _________________________________________________

Others notified / by whom / date:
_____________________________________________________________________________________
_____________________________________________________________________________________

Was a 51A report filed? Yes_________ No ________
Additional Notes:
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