Appendix E - Student Grade Appeals Form
Student Information
Student’s Name Local Address
Phone
Course Information
Course Number & Title _________________________________
Semester ____________________________________________Professor’s Name ______________________________________
Grade Received in Course Grade Expected in Course
Number of Class or Rotation Absences ______________________________
Date of meeting with instructor about grade received
Was a change of grade requested? Yes No
Basis of Grade Appeal Request:
Personal Bias Arbitrary Grading Clerical Error
Please attach a separate sheet explaining the reason for requesting a grade change, any discussions with the instructor about your class performance prior receiving the disputed grade and during the meeting to discuss the grade, and the outcome of the meeting with the professor.
Provide documentation of class performance, including laboratory portions of the course if applicable.
Include copies (not originals) of:
- Syllabus and other course materials (handouts, assignments, etc.)
- All tests, assignments, papers, etc. returned by the professor
- Any other pertinent materials or information
Student Signature Date
This form is to be filed with the department chairperson no later than one week after the final course grade is posted. Please retain copies of all information filed with this statement.