Academic Complaint Form - Cleary University

This form is for academic-related complaints against a faculty member, such as grade disputes and other disputes of an academic nature. This form should be filled out by the student, and will be submitted to the Ombudsman in the event that the student and faculty member cannont resolve the issue in question and after a conference with the instructor has occured.

Student ID #*
Student Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Course*
Name of Instructor*
Describe the issue*
Please describe the issue giving rise to your complaint in as much detail as possible. Include any places, dates and/or times you can recall. Nore: Students must include evidence to support their request, as well as copies of any relevant documents (e.g., course syllabus, email chains).
Attempts to Resolve*
Describe your attempts to resolve this with the instructor and the outcome of the meeting. Note: A conference with the instructor must be scheduled outside of classroom hours. THIS IS REQUIRED PRIOR TO SUBMITTING THIS FORM.
Expected Outcomes*
Please describe as clearly as you can what would resolve this issue in a satisfactory manner, in your opinion.

Ombudsman will evaluate, and send it to the appropriate departmental chair within 5 business days. The department chair will then arrange a meeting with you and the instructor within ten (10) days of receipt of this completed form.

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