University of Minnesota s9

Route this form to: U Wide Form: UM 1698 Student Academic Complaint Rev: 11/25/08

This form supports the Administrative Procedure: Conflict Resolution Process for Student Academic Complaints: Twin Cities

Student Filing Petition Name: College/Program: Contact Information:

Factual Basis of Complaint Describe action being questioned and include all relevant dates.

University Rule, Policy or Practice Identify the specific University rule, policy, or practice that is believed to have been violated.

Person(s) Responsible for the Action (If Known)

Proposed Remedy Identify a remedy that is within the authority of the University to grant under the Conflict Resolution Process for Student Academic Complaints: Twin Cities.

Signature: ______Date:

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