Complaint Submission Form at HSHS St. John's College of Nursing

First Name

Last Name

Student ID

Phone Number

Program

BSN LPN-BSN RN-BSN MSN Other

Semester/Year

Category of Complaint

Academic (grades, teaching, curriculum) Clinical/Practicum Site Facilities or Equipment Student Conduct Faculty/Staff Conduct Safety or Security Discrimination or Harassment Other

If Other, please describe

Date of Incident or Concern

Describe the Incident in Detail

Include relevant names, dates, what happened, and any steps you have already taken.

Steps taken to resolve the issue informally

What action or resolution are you seeking (if any)?

Do you have any supporting documents?

Yes No

Please attach documents here

Please select a file

Certification & Signature

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that this complaint will be reviewed in accordance with the Student Complaint and Grievance Policy, and that retaliation for filing a grievance in good faith is strictly prohibited. by the appropriate College personnel and that I may be contacted for additional information, if needed.

Digital Signature

Type Full Name

Today's Date