Student Complaint Form Imminent Danger Advisory Acknowledged If you believe that you, or another person, are in imminent danger of harm, DO NOT USE THIS FORM. Please contact Public Safety at 718-262-2222 or dial 911 immediately - Public Safety office is located in the Academic Core Building, Room 1M02 False Complaint Advisory I Acknowledge and confirm Knowing submission of a false complaint through this portal is misconduct and subject to discipline under the Student Conduct Code & applicable collective bargaining agreement. First Name Provide your first name Last Name Provide your last name EMPL ID Phone Number to reach you York College E-Mail Address Classification --Please Select--Undergraduate StudentGraduate Student Which of the following most closely defines your affiliation to York College? Year Classification No value--Please Select--FreshmanSophomoreJuniorSeniorOther Academic School No value--Please Select--School of Arts & SciencesSchool of Business & Information SystemsSchool of Health Sciences & Professional Programs Major No value--Please Select--Undeclared majorAccounting BSAnthropology BAArt History BAArt Studio BAAviation Management BSAviation Management CERTBio Technology BSBiology BABiology BSBiology Teacher Educ 1-6 BSBlack Studies BABusiness Adminstration BSChemistry BAChemistry BSChemistry Middle School BSChemistry Teacher Educ 1-6 BSClinical Lab Science/MT BSCommunications Technology BSCommunity Health Education BSComputer Science BSCreole for Professionals CERTCUNY Baccalaureate BACUNY Baccalaureate BSCUNY Permit GraduateCUNY Permit UndergraduateEarth Science /Education 7-12 BSEconomics BAEnglish BAEnglish Teacher 1-6 BAEnv Health Science BSFine Arts BAFrench BAGeology BSGerontological Studies BSHealth Education Pre K-12 BSHealth Promotion Management BSHealth Science BSHistory BAHistory Teacher Educ 1-6 BAInformation Systems Management BSInterdis Std Teacher Ed 1-6 BAInterdisciplinary Studies BAJournalism BAMarketing BSMath Teacher Educ 1-6 BAMath Teacher Educ 7-12 BSMathematics BAMathematics BSMovement Science BSMusic BAMusic Teacher Educ 1-6 BANon Degree GraduateNon Degree UndergraduateNursing BSNursing(RN) BSOccupational Therapy BSMSPharmaceutical Sci & Bus MSPharmaceutical Sciences BSPhilosophy BAPhysical Education Teacher Pre K-12 BSPhysician Assistant BSPhysician Assistant MSPhysics BSPolitcal Science BAPsychology Teacher Educ 1-6 BAPsychologyPublic HealthSocial Work BSSociology BASociology Teacher Educ 1-6 BASpanish BASpanish for Professionals CERTSpanish Teacher 7-12 BASpeech BSSpeech Theatre Arts BA Current Status No value--Please Select--AttendingGraduatedNot AttendingOther Location of Incident No value--Please Select--York CollegeOff CampusOther Select the main location of where the Incident occurred Date of Incident Most recent event Time of Incident Approximate time of recent event (please add AM or PM after time) Provide Name(s) of person(s) or write unknown Who are you filling a complaint against? No value--Please Select--Undergraduate StudentGraduate StudentFaculty / ProfessorStaffUnknown Type of Complaint No value--Please Select--Academic policy/procedureServicesSafetyAdministrationTechnologyStaffFacilitiesInstructorOther Detailed Description Please describe your complaint in detail. Include names of persons, locations, and dates involved. If this complaint is against specific person(s), please list their names and titles. Also, if you selected "Other" from any of the fields please indicate here what "Other" is. Attempts What attempts have you made to resolve this complaint up to now? Please state who you have contacted and what transpired? (Relate any actions you have already taken to address this concern. For example: spoke with professor, spoke with advisor, contacted the appropriate office, etc.) What is your desired outcome? Note: If yes, please provide us with the name of the organization(s) and the outcome. Campus Security --Please Select--YesNo Has this incident been reported to Public Safety? Law Enforcement --Please Select--YesNo Has this incident been reported to law enforcement? Additional Information Any other information you want to provide? Attachments If attachments are necessary, please include as a .jpg or .pdf Submission I Acknowledge and confirm By submitting this complaint you affirm that the above allegation is true to the best of your knowledge, information and belief. Submit
