Hazard Community and Technical College

STUDENT COMPLAINTS PROCEDURE

FORMAL COMPLAINTS FORM

This form is designed for use with the Formal Stage of the HCTC’s Student Complaints Procedure.
Please ensure that you have read and understood the Procedure before completing this form.
The completed form should be returned to the President’s Office, Jolly Classroom Building
on the Hazard Campus.

Part I - Student Information

Name

Address (for response)

Student ID No.

Telephone No

Email:

Part II – Details of Complaint
(Please explain what you are complaining about and why.
Please feel free to attach additional sheets if necessary)

…………………………………………………………………………………………………………
Section III – Redress  (Please state clearly what redress you are seeking)

Section IV
Before a complaint can be raised formally, it must have been raised informally with one or
more of the following:

1. Lowest level – Instructor, etc.
2. Department or Unit Director/Head
3. Department or Unit Vice President

Please indicate below where the complaint has been raised

(1)        Name: 

            Title:    

            Date Raised:    

(2)        Name: 

            Title:    

            Date Raised:    

What was the outcome: (please include why you are still dissatisfied)

……………………………………………………………………………………………………...

Signature of complainant: _____________________________________________ 

Date:   

For office use only

Date received:  ____________________________________________________________

Acknowledgement date sent: ________________________________________________

Referral Made for Follow-up
Employee Name: __________________________________________________________

Date:   __________________________________________________________________