Complaint Form

 

Student Judicial System Complaint Form

Missouri State University

 

 Name of Complainant____________________________________________ SSN_________/______/__________

Address:______________________________________________________________________________________

Phone #______________________________________ You are:  ______ Student  ______ Staff   ______  Faculty

 

Name of Accused:______________________________________________________________________________

Address: ______________________________________________________________________________________

Date, time, and place alleged violation(s) occurred: ____________________________________________________

______________________________________________________________________________________________

Witnesses, if any, to the alleged violation (attach if necessary):  _________________________________________

______________________________________________________________________________________________

Concise description of the alleged violation (attach if necessary):_________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Physical items that will be presented:_______________________________________________________________

______________________________________________________________________________________________

If the accused pleads "responsible", what sanctions do you recommend? _____________________________________

______________________________________________________________________________________________

I understand that in compliance with the Family Eductional Rights and Privacy Act (FERPA), Missouri State University must obtain written consent of a student before releasing identifiable data about the student from records, unless release of records falls within exceptions permitted in the provisions of FERPA and Unviersity policy which allow disclosure without prior written consent.  The policy regarding personally identifiable student records is availabe in the Dean of Students Office, 4th floor, Plaster Student Union, 417-836-5527, and on the Missouri State University web site at www.Missouristate.edu/judicial/policies/studrec.htm

I state that the above information is true and that I would like University charges filed against this individual (or organization). Secondly, I authorize disclosure of my name and the nature of this complaint in conjunction with the disciplinary process.

 

__________________________________________________      _________________________

Signature                                                                                                         Date