Submit the completed form and supporting documents to appeals@xusom.com or the Office of Student Affairs. Reporting within ninety (90) calendar days is encouraged; later reports may also be considered. Use additional pages where needed.
Name of complainant
________________________________________________________________________________
Program or department
________________________________________________________________________________
Date and preferred confidential contact details
________________________________________________________________________________
Name and role of person or persons concerned
________________________________________________________________________________
Incident dates times and locations
________________________________________________________________________________
Witness names and contact details
________________________________________________________________________________
Description of the incident and supporting facts
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Requested resolution
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Attachments provided: ☐ Emails ☐ Messages ☐ Photographs ☐ Witness statements ☐ Other
I certify that the information provided is true and accurate to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action; a good-faith report is protected even if it is not substantiated.
Signature and date
________________________________________________________________________________
For official use
Date received and receiving officer
________________________________________________________________________________
Reference number and referral
________________________________________________________________________________
Outcome action and closure date
________________________________________________________________________________