LURLEEN B. WALLACE COMMUNITY COLLEGE
Student Grievance Form
Submit this form to the Dean of Student Affairs in person in the Jeff Bishop Student Center, Andalusia campus; via fax to (334) 881-2201; or via email to jjessie@lbwcc.edu.
COMPLAINTANT INFORMATION
Name: ___________________________________________________________________________
Address to send correspondence: ______________________________________________________
City: __________________________ State: __________________ Zip: ______________
Telephone: ___________________________
Email: __________________________________
Name of the person/s your grievance is against: ___________________________________________
What date/s did the actions occur: ______________________________________________________
What do you allege occurred? (Please be specific, provide details and use the reverse of this sheet if needed.) ___________________________________________________________________________
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Is there a specific law or College/ACCS policy/guideline you believe has been violated? If so, which one/s?
_________________________________________________________________________________
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In your opinion, what can be done to reasonably resolve this grievance? _______________________
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Print Name
Date
Signature
This section should be completed by the Dean of Student Affairs.
_____________________________________
_____________________________
Signature
Date Form Received
286
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2022-23 College Catalog and Student Handbook
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