Student Complaint Form B次元 Mercy Student Complaint Form Student Complaint Form B次元 Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields Student Complaint Form This form can be used by students to file a complaint regarding faculty in the academic setting(s), regarding other employees, contractors or vendors, or regarding student services or other University services. Who is making the complaint? First Name * First Name* Last Name* CWID * Phone * Email * Status* Undergrad Grad Campus/Home Address* Address Line 1 Address Line 2 City 听 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Complaint Information Date(s) on which the event(s) or issue(s) occurred * https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Dobbs Ferry* Dobbs Ferry Bronx Manhattan Online Name(s) of the person(s) involved * Where did this complaint take place? * - Where did this complaint take place? (required) - Class Department Other Provide Class Name, CRN, School Department Please describe other location Please describe your complaint in detail. Include the names of persons, locations, and dates involved. If this complaint is against specific person(s), please list their names and titles. (Attach a separate page if needed.) * Please attach additional information No File Chosen File uploads may not work on some mobile devices. What attempts have you made to resolve this complaint up to now? Please state who you contacted and what transpired. * Why do you think the complaint was not able to be resolved in your prior attempts? * What resolution would you consider fair? What resolution do you seek? * Is there any person who you do NOT want to be told of your complaint? * I hereby certify that the above information is true and correct to the best of my knowledge and belief. I grant permission for this complaint to be forwarded to B次元 officials for purposes of investigation and response.* Yes No I agree to provide such other or supplemental information that may be requested. Receive Text* Yes No Previous鈫 Next鈫 Enter your save and resume password Cancel Confirm
