FLD EXHIBIT

ANGELINA COLLEGE STUDENT COMPLAINT AND APPEAL FORM

All formal complaints and appeals must be submitted using this form, and all fields must be completed. If a field is not relevant, write “N/A” in the space provided. Please note that complaints alleging discrimination, including violations of Title IX (gender), Title VII (sex, race, color, religion, national origin), ADEA (age), or Section 504(disability), must be submitted to the Executive Director of Student Affairs, Administration Building room 204-A, and in accordance with Angelina College policy.

Student Name: _____________________________ Date: ___________________

Mailing Address: _________________________________________________________________

Email Address: _____________________________ Phone Number: __________________

Select One Option by Filling in the Corresponding Circle:

○	LEVEL ONE: Staff Member or Faculty Member	OR	○	DISCRIMINATION
○	LEVEL TWO: Appeal to Next Level Supervisor		Title IX & Title VII: submit form to Dean of Student Affairs ADEA, ADA & Section 504: submit form to Director of Human Resources All other Discrimination: submit form to College President Protected class of complainant: __________________
○	LEVEL THREE: Appeal to Executive
○	LEVEL FOUR: Appeal to College President

You may attach any relevant documents to this form. You may also attach additional pages if the spaces provided below are insufficient. If you choose to attach additional pages, please write “see attached” in the space(s) below.

Complaint

Be specific (e.g., full names - including the name(s) of responsible person(s), date the alleged incident occurred, location(s), relevant rule(s) & regulation(s), etc.). The complaint must be in relation to an incident that has already occurred. Do not reference multiple matters or matters already addressed in a complaint you previously submitted.

Adverse Effect: Explain how the alleged action or issue adversely affected you.

Requested Relief: State the specific corrective action or relief you are requesting. The corrective action or requested relief must be within the authority of AC to grant.

Names of Witnesses who have firsthand knowledge of the events being complained:

_________________________________ ____________________________________

__________________________________________________ ______________________________________________________

Name of Representative: ____________________________○ No Representative Chosen

“Representative” means any person who or organization that is designated by an individual to represent the individual in the complaint process. The individual may designate a representative through written notice to the College at any level of this process. If the individual designates a representative with fewer than three days’ notice to the College before a scheduled conference or hearing, the College may reschedule the conference or hearing to a later date, if desired, in order to include the College’s counsel.

SIGNATURE

_________________________________________ ____________________

SIGNATURE DATE

__________________________________________

PRINTED NAME

The Executive Director of Student Affairs is responsible for reviewing and updating this exhibit. Policy reviews are made in accordance with the Office of Institutional Effectiveness Policy Tracking document.