Student Grievance Report Form

Please complete the form below. If you choose to make an anonymous or confidential grievance, please understand that our ability to resolve the grievance may be limited.

Background Information on Reporter

First Name

Middle Name

Last Name

Campus or Local Address

LR Email

Please provide your @my.lr.edu or @lr.edu email address.

Phone

Student ID Number (000 Number)

Background Information of Alleged Person or Organization

Name or Organization

Information Regarding Complaint

Date & Time of Complaint

Location of Complaint

Type of Complaint

Identify the policies you believe were violated.

Description of Complaint

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Student Grievance Report Form

Background Information on Reporter

Background Information of Alleged Person or Organization

Information Regarding Complaint