Student Concern Form
Please complete all fields so your concern may be directed to the proper university officials.
(In compliance with federal regulations, UI&U will maintain a log of submitted forms.)
Full Name (First Last)
Name while enrolled
Program and Major
Mailing address
Address 2
City
State
Zip Code
Your Preferred Email Address
Telephone
Union ID
Last Date of Attendance
Preferred Method of Contact
First date on which the events or issues occurred
Name(s) of the person(s) involved
Please describe your concern in detail. Include the names of persons, locations, and dates involved. If this concern regards specific person(s), please list their names and titles.
What attempts have you made to resolve this concern up to now? Please state who you contacted and what transpired.
Why do you think the concern was not able to be resolved in your prior attempts?
What resolution would you consider fair? What resolution do you seek?
Is there any other information you would like to provide?
Optional: Attach documents in support of your concern here.
Attachment 1
Attachment 2
Attachment 3
Certification
I certify that the above information is true and correct to the best of my knowledge and belief. I grant permission for this concern to be forwarded to UI&U officials for purposes of investigation and response. By signing and submitting this concern, I authorize Union Institute & University to follow up on this issue as needed. I understand that Union Institute & University may contact me for additional information. Please type your name below.
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