Student Non-Academic Complaint Form

This form is used by students to initiate the formal written student complaint procedures as outlined in the South Georgia State College Student Handbook.

This section is to be completed by the person filing the complaint:

Your Name *

First Name

Last Name

Your Student ID *

Your Phone Number *

Your Email *

Your Full Address *

Address Line 1

City

State

Zip

Person Accused

Full Name *

First Name

Last Name

Date of Incident(s)

Location of Incident(s)

Incident Description Describe the incident in the text box. Be sure to include your desired outcome or resolution of your complaint.

Date Submitted *

Names of other persons with information about the complaint:

Full Name

First Name

Last Name

Phone Number

Full Name

First Name

Last Name

Phone Number

Was the informal report and resolution process followed?

YES

Name the advocate or staff person who assisted with the formal process:

Full Name

First Name

Last Name

Department

Student Non-Academic Complaint Form