Student Feedback Form Instructions: Students who have a concern/complaint or compliment about their Shasta College experience should complete this form and submit it to the Business, Agriculture, Industry, Technology & Safety division office by emailing it to baitinfo@shastacollege.edu. Students should allow 10 business days to receive a written response to their feedback through the email provided. The college is unable to provide a written response to anonymous feedback.

Check one:

Name of individual and department about whom the feedback is regarding:

If this is in regard to a concern/complaint, have you made an attempt to resolve the situation with the individual and/or department involved? Yes NoIf yes, describe the outcome: (Attach any additional comments, if necessary.)

Describe your feedback in detail. If this is in regards to a concern/complaint, please include date(s) of occurrence(s) (be as specific as possible). Attach additional comments or documentation that will help describe and substantiate the statements.

What would you like to see happen as a result of bringing this forward? Attach additional sheets, if necessary.

Date:

Student Name: Student ID#

Email Address: Best phone number to be reached:

Semester/Year:

Current student:

Signature

*Concerns or complaints using this form should be submitted only after you have made an attempt to complete the “First Level” of the StudentGrievance Procedure pursuant to the Shasta College catalog wherein it states that “any student with a grievance should first attempt to resolve thematter by means of an informal meeting with the person(s) against whom the student has the grievance.”

Compliment

Yes No

Concern/Complaint*

I understand that information contained on this form will be held confidential to the extent possible. Feedback information may be shared with college officials in order to conduct a thorough investigation, if warranted; however, acts or attempts to retaliate or seek retribution against the complainant or any individual or group involved in the complaint, investigation and/or resolution of an allegation is strictly prohibited. Students experiencing any form of retaliation should report it immediately to the office of the appropriate Vice President. I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary actions in accordance with college disciplinary policies. If a student name is not provided, this comment will be for informational purposes only. By checking this box, I would like my comments to remain anonymous moving forward.

Does this comment concern a particular course? Yes No If yes, please specify Course and Section Number ______________________

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Describe your comment in detail Include dates of occurrence be as specific as possible Attach additional comments if necessary along with any documentation that will help describe and substantiate the statements: What outcome do you hope to achieve after talking to the appropriate college officials Attach additional sheets if necessary: Date: Concern/Complaint: OffReset Form: Email Address: Student Name: 7-digit Student ID #: Phone Number: Current Student: OffSignature Field: Example: S2017, U2017, F2017: Attempt to Resolve: OffName of individual and department about whom the comment is filed: Students are encouraged to discuss their comment through informal conferences with the appropriate instructor or other College employee Have you made an attempt to resolve the situation with the individual andor department involved Yes No If yes describe the outcome Attach any additional comments if necessary: Check Box1: OffParticular Course: OffCourse\Section: