Student Input Form

Date event occurred:

mmddyyyy

Student name:

 

Student ID#:

 

Check One:

Former Student Current Student Future StudentOther

Individual / Area / Office / Department / Division - being commented on:

 

 

Identify the category of your complaint

(check all that apply):

  service building individual coursework other

 

Describe the issue or concern.

(please be specific regarding

who, what, when, and where)

 

Have you talked with staff or the

instructor regarding your concern?

If yes, please describe the outcome:

Student contact information:

Street address:

City:

 

State:

Zip:

Phone Number:

 --

Email:

When addressing my concern (please check one):

 

You may use my name

You may use my name only after the end of the semester

You may not use my name

How did you find out about this process?

 

     

   

CNM will not allow any form of retaliation against individuals who file a complaint to CNM management,

or who cooperate in the investigation of such reports. To the extent possible,

the confidentiality of the reports will be maintained.