Middlesex Community College

Student Complaint Form

To initiate a complaint, a student must complete and submit this form.  Your form will be received by the Office of Community Standards where it will be reviewed and shared with appropriate staff.

If you have any questions regarding the form or the status of a submitted complaint/inquiry, please contact the Office of Community Standards at communitystandards@middlesex.mass.edu.

First Name

Last Name

Student ID/A#

Email Address

Phone (XXX-XXX-XXXX)

Street Address

City

State (e.g. MA)

Zip Code

Country

---

Please describe your complaint/inquiry in detail. Include all relevant names or other pertinent information.

If your complaint is related to a course, please complete the section below (otherwise, leave blank)

Course Information

Course Title

Course Number and Section
(Ex. CRJ 101-50)

Year

Semester

Spring

Summer

Fall

Winter

Minimester

Instructor's Name

Course Format

In Person

Online

Blended/Hybrid (On Campus and Online)

Describe any action you have taken to resolve this matter.

For any non-academic complaints or other items, please use this space.

---

Do you have any documents you wish to submit to support the facts set forth in this form?
Please email them to communitystandards@middlesex.mass.edu

Signature
(Please type your full name here)

 

 

33 Kearney Square, Suite 407, Lowell, MA 01852
Phone:   978-656-3394  Fax:   978-656-3422