University of Arkansas at Pine Bluff Division of Academic Affairs Student Complaint Form

Please complete this form to escalate academic matters to the Provost and Vice Chancellor for Academic Affairs. As a reminder, the instructor, your academic advisor, the department chair, then the dean of the academic school (ex. School of Arts and Sciences) should be consulted prior to appealing to the Provost.

Note: You will be contacted by the telephone number provided on this form or your UAPB email address.

Type N/A for any item that is not applicable to your complaint.

1.First and Last Name

2.Student ID Number

3.Telephone Number (Include Area Code) XXX-XXX-XXXX

4.Major

List Other

6.Anticipated Graduation Term (ex. Spring 2022)

7.Academic School

8.Please discuss your problem/concern

9.How can the Office of Academic Affairs assist you?

10.If this a class concern, did you consult the instructor? If yes, please proceed. If no, please follow the academic chain as provided in the instructions prior to submitting this form.

YesNo

11.Who is the instructor?

12.What is the name of the course(s)?

13.What was the instructor's response?

14.Have you consulted with your academic advisor? If yes, please proceed. If no, please follow the academic chain as provided in the instructions prior to submitting this form.

YesNo

15.Who is your academic advisor?

16.What was your academic advisor's response?

17.Have you consulted with the department chairperson? If yes, please proceed. If no, please follow the academic chain as provided in the instructions prior to submitting this form.

YesNo

18.Who is the department chairperson?

19.What was the department chairperson's response?

20.Have you consulted with the academic dean? If yes, please proceed. If no, please follow the academic chain as provided in the instructions prior to submitting this form.

YesNo

21.What was the response of your academic dean?

22.Is there any additional information you would like to provide?

Contact Information