Student Complaint Form

1. Personal Information

Please refer to the Student Complaint Reporting Policy before submitting this form. This form is to be used to submit a formal complaint students have been unable to satisfactorily resolve with the faculty, staff, students or others involved. This form is to only be submitted by students. Please complete all fields so your complaint may be directed to the proper University officials. Complaints may be submitted anonymously; however, unless you include your contact information, Southern University will be unable to investigate your complaint or respond back to you regarding the matter.

Full Legal Name(as enrolled)

S-Number

Major

Mailing Address

SUBR Email Address Only

Phone Number

Preferred Method of Contact

Phone

U.S. Mail

2. Information about your complaint:

Date on which the event(s) or issue(s) occured:

Name(s) of the person(s) involved:

Please describe your complaint in detail. Include the names of persons, locations, and dates involved. If this complaint is against specific person(s), please list their names and titles.

Complaint

What attempts have you made to resolve this complaint up to now? Please state who you contacted and what transpired.

Attempts

What resolution would you consider fair? What resolution do you seek?

Resolution

Why do you think the complaint was not able to be resolved in your prior attempts?

Prior attempts

Any other information you want to provide?

Details

For instance, is there any person who you do NOT want to be told of your complaint? (Keep in mind that it may be difficult to resolve if those involved cannot be asked to explain or respond).

3. Certification

I hereby certify that the above information is true and correct to the best of my knowledge and belief. I grant permission for this complaint to be forwarded to Southern University officials for purposes of investigation and response.