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GB EXHIBIT

ANGELINA COLLEGE

PUBLIC 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. 

Complainant Name: _____________________________      Field 2 Date: ___________________

Mailing Address: _________________________________________________________________

Email Address: _____________________________ Field 5 Phone Number: __________________ 

Select One Option by Filling in the Corresponding Circle:

Levels

Filing Instructions

○  Level One

File with the appropriate College administrator who has the authority to address the concern

○  Level Two

File with the College President or designee

○  Level Three

File with the Office of the President for appeal to the Board of Trustees

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 grieved:

__________________________________________ __________________________________________

__________________________________________ ___________________________________________

Name of Representative: _________________________________________ 

“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