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INSTRUCTIONS:  Please read the Student Grievance Procedure before completing this form.  Be sure to observe the time limits specified in the procedure.  You are also encouraged to attempt to resolve the matter at the local level if possible.  It is not required that you use this form, but please include all the information below in your complaint.  Submit formal grievances to:

                Vice President for Student Affairs
                501 Vine Street
                Scranton PA 18509
                Email:  Musewiczs@lackawanna.edu


 

Grievant Name:

 

Email Address:

 

Address 1:

 

Address 2:

 

City:

 

State:

 

Zip:

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Phone Number:

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Name of individual whose conduct is being grieved:

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Date(s) of most recent occurrence(s) leading to this complaint:

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Result of prior attempts to resolve this matter at the department level:

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Date you received department level response:

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Provide a short description of action(s) being grieved:

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State the resulting injury or harm because of this action:

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Provide a description of any evidence supporting the grievance:

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State the remedy or relief you are requesting:

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Please submit any additional background information that will be helpful in resolving your grievance:

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I understand that checking this box constitutes a legal signature confirming truthfulness of the information provided in this form.