Problem Resolution Form

Information on Person Reporting Problem

Your Name:

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Name of person reporting problem

CCC ID Number:

Your phone number:

Your email address:

Email address must be of a valid format.

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Please use your @student.clackamas.edu email address.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Name of other person(s) involved

Please provide any information you have of the other person (s) involved.

Other person (s) involved

Select Gender

Phone number

Email address

Questions

Did you speak with the person involved in the incident prior to filling out this form? • If yes, describe the informal process you used and the outcome. • If no, please state why an informal discussion about the issue did not take place.(Required) This field is required.

Please describe the incident in as much detail as possible, include names and other important infor-mation. • Reference CCC’s policies and procedures in the Student Handbook as they apply.(Required) This field is required.

Please describe, as clearly as you can, what you believe would be the best solution to this problem. • Reference CCC’s policies and procedures in the Student Handbook as they apply.(Required) This field is required.

Please read and mark the check box of all the following to acknowledge that you understand Clackamas Community College’s Disciplinary Appeal Procedures.(Required)

I have read CCC’s Problem Resolution Procedures in the current academic year’s Student Handbook.

I understand that this form must be submitted to the appropriate supervisor or associate dean within thirty (30) working days of the end of the term in which the problem occurred.

I understand the importance of maintaining confidentiality and respect for all parties involved during the review process.

The statements herein are true and accurate.

I understand that the associate dean or supervisor will gather necessary evidence to make a decision, and this may require me, the student, to meet with the staff member involved at the associate dean or supervisor’s request.

I understand that after the associate dean or supervisor has decided upon the outcome, s/he will provide me, the student, a written explanation of the decision or a status update within ten (10) working days of the receiving the Problem Resolution Form.

You must make at least one selection.

Supporting Documentation

Please attach any supporting documents relevant to your submission. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Information on Person Reporting Problem

Name of other person(s) involved

Questions

Supporting Documentation

Submission