PUBLIC COMPLAINT AND APPEAL FORM

If you would prefer to fill out a physical copy, it can be downloaded by clicking the file name to the right. It can be mailed into 3500 South First St,
Lufkin, TX 75904 or turned in at the Admin Building to the Receptionist. 

All formal complaints and appeals must be submitted using this form, and all fields must be completed. If a field is not relevant, write "N/A" in the space provided.

All fields marked with (*) are required

Complainant's Name:

Mailing Address:

Email Address:

Phone Number:

To view Public GB Local Policy and better understand Complaint levels, Please download document to the right.

LEVEL                         FILING INSTRUCTIONS                                                                           

COMPLAINT

Be specific (e.g., full names -including the name(s) of responsible person(s), date the alleged incident occurred, location(s), relevant rule(s) and regulation(s), ect.) The complaint must be in relation to an incident that has already occurred. Do not reference multiple matters or matters already addressed in a previously submitted complaint.

ADVERSE EFFECT

Explain how the alleged action or issue adversely affected you.

REQUESTED RELIEF

State the specific corrective action or relief you are requesting. The corrective action or requested relief must be within the authority of AC to grant.

NAME(S) OF WITNESS(ES) who have first hand knowledge of the events being grieved. Please use commas between names.

NAME OF REPRESENTATIVE  

"Representative" means any person who, or organization that is designated by an individual to represent the individual in the complaint process. The individual may designate a representative through written notice to the College before a scheduled conference or hearing. The College may reschedule the conference or hearing to a later date, if desired, in order to include the College's counsel.

Select this box if you choose not to have a representative

You may attach any relevant documents to this form. You may also attach additional pages if the spaces provided below are inefficient. If you choose to attach additional pages, please write "see attached" in the space(s) below.

ELECTRONIC SIGNATURE, Please type your full name.

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

TODAYS DATE

ADMINISTRATIVE USE ONLY

Name of administrator who received this form:

Date complaint was received:

Date of complaint conference or hearing:

Date written response sent to complainant:

Administrator must retain the following: (a) the original complaint form and attachments; (b) all other documents submitted by the employee (Level One only); (c) the written response issued by the supervisor/administrator and any attachment; (d) all other documents relied upon by the supervisor/administrator in reaching the decision; and (e) any recordings of conferences.

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