Student Grievance Form

The Department of Psychology is dedicated to resolving student issues in a fair and equitable manner, consistent with course policies, as well as the policies of the Department and the University. Please complete all fields below so that we can best direct your issue to the appropriate person.

If the issue is related to a grievance about a course, you must first attempt to resolve the issue with your instructor. This form should not be completed until the issue has first been discussed with the instructor and a serious effort has been made to resolve it.
We appreciate you bringing this issue to our attention.

Please all fields are required.

Name Name * First Last
UTA ID Number (1000 number) *
Email *
Phone Phone * - ### - ### ####
Today's date Today's date * / MM / DD YYYY
Course Number *
Course Name *
Course Instructor *
Semester course was taken *

Semester course was taken Fall Spring Summer Other Other
Date issue occurred Date issue occurred * / MM / DD YYYY
Clearly and concisely describe the issue: *
Describe any actions you have taken to resolve the issue: *
Describe the outcome of the actions you have taken to resolve the issue: *
What is your desired resolution? *
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