LBCC - Student Non-Academic Complaint

Background Information

Your First Name: *

Your Last Name: *

LBCC Student ID Number:

Student Status: *

Your Phone Number: *

Your Email Address: *

Your Physical Address: *

Complaint Regarding: *

LBCC Dept

LBCC Faculty/Staff

LBCC Student

Non-Student

Please Specify: *

Priority: *

Date of Incident: *

Time of Incident: *

Location of Incident: *

Involved Parties

Please list all parties involved or who have direct information regarding this complaint.

Name or Organization or Individual: *

Phone Number:

Email Address:

Questions

The Complaint/Non-Academic Form should be submitted immediately. This generally ensures the availability of all parties involved in the complaint. When completing the Non-Academic Complaint Form, the reporter is expected to respond to all of the following questions as it relates to the complaint.

What is the nature of the complaint? *

What steps have you already taken to resolve the issue? *

What resolution or outcome are you seeking from this process? Provide specific actions you would like to occur as a result of filing this complaint. *

What is the best way to contact you? *

E-Mail

Phone Call

Text

In order for this complaint to be processed, please read and affirm (by clicking the check box) all of the following: *

I hereby attest that the above information is true and accurate to the best of my knowledge. I will provide additional information and supporting documentation upon request.

I hereby authorize the Vice President of Student Services and/or designee, to disclose the information submitted in this complaint to the person(s) against which the complaint is filed.

I understand that the Vice President of Student Services or designee, may dismiss the complaint if an investigation determines that the complaint is without merit.

I hereby affirm that I have executed this form either on my own behalf OR on behalf of the complainant fo the specific purposes I describe.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below.

Attachments require time to upload, so please be patient after submitting this form.

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