Pima County Community College District

Your Name & Contact Information

Prefix

(Select one)

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First Name

M.I.

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Last Name

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Phone Number (day)

Include the area code, extension, and/or dialing codes if applicable.

Phone Number (evening)

Include the area code, extension, and/or dialing codes if applicable.

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Student ID

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Email

(Format: username@domain.com)

Address

City

State

ZIP Code

Location

Click the button labeled Look-Up to locate and select a location. If the location you are looking for is not available, select the location labeled Other / Not Listed, and then enter the location information in the form manually.

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Name

Clear Look-Up

Issue

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Select the type of issue that best represents the incident.

(Select one)

Description:

No type of issue or event selected.

Date

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Approximate date of issue/incident.

Format: mm/dd/yyyy

Details

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State your formal complaint. Please provide statements of fact and nature of complaint.

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How did this situation develop? (Outline, in chronological order, the basic components of this situation as they developed including pertinent dates and times. If you have additional supporting documentation, please email to resolution@pima.edu)

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How have you attempted to resolve this situation? Describe the suggested resolution.

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What specific remedies (actions) do you desire to resolve this complaint?

Inquiry

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Provide the details of your inquiry/question.

Participants

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Were any Participants involved in this incident?

Yes No Unknown

(Select one)

Student Complaint Form

Statement of Purpose

Student Complaint Form

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Statement of Purpose