This form is used to begin the appeal process under Policy 72. Resources to advise students include the Conflict Management and Human Rights Office, Ombudsperson, Secretariat and Faculty Undergraduate and Graduate Offices.

The completed form with supporting documentation is to be submitted to the Chair of the appropriate Faculty Committee on Student Appeals (FCSA) (c/o Office of the Dean of the Faculty) within 10 working days of being notified of:

• a grievance decision in an academic setting made by an Associate Dean under Policy 70 - Student Petitions and Grievances
• the decision of the Associate Dean of the Faculty under Policy 71 - Student Discipline where the penalty imposed does not include suspension for more than three consecutive terms or expulsion (in those cases the University Committee on Student Appeals has jurisdiction)

The completed form with supporting documentation is to be submitted to the Chair of the University Committee on Student Appeals (UCSA) (c/o Secretariat, Needles Hall) within 10 working days of being notified of:

• a discipline penalty imposed under Policy 33 - Ethical Behaviour
• a grievance decision in an academic support setting made under Policy 70 - Student Petitions and Grievances
• a decision of an Associate Dean under Policy 71 - Student Discipline where the penalty imposed includes suspension for more than three consecutive terms or expulsion
• a decision of the Vice-President, Academic & Provost under Policy 71 - Student Discipline
• a decision of a Faculty Committee on Student Appeals

Student Information:
Last Name:
First Name:
ID Number:
Faculty: Applied Health Sciences Arts Engineering Environment Mathematics Science
Program:

Local Contact Information:
Street Address:
City:
Postal Code:
Email Address:
Telephone Number :
Note: It is the student’s responsibility to immediately report any change to this contact information.

Written responses to the following items must be provided below or typed on additional sheets.

Name and title of the individual/committee whose decision is being appealed. [Attach a copy of the decision.]

Appeal Type:
Select one of the following: The appeal is against the finding that my conduct amounted to misconduct. The appeal is for relief of the penalty imposed. The appeal is against the finding of misconduct and for relief of the penalty imposed.

The outcome of the case at the original hearing:
Select: Might have been substantially affected by the circumstance(s) indicated below:

Select any of the following that apply. You must choose at least one.

Details of the Appeal
Set out the reasons for appealing the decision, including an explanation of the circumstance(s) claimed above as a ground for the appeal.

Relief Requested
Set out the result you are seeking.  

Witnesses
Note: The student is responsible for ensuring the availability of his/her witnesses for the hearing and for notifying each witness of the date, time and location of the hearing.
Select one: I will not be calling any witnesses. I will be calling the following witnesses:

Identify any witnesses you intend to call (name, address, telephone number, email address) and a brief statement of the evidence you expect each will give.

Support Person
Note: The student is responsible for ensuring the availability of his/her support for the hearing and for notifying that person of the date, time and location of the hearing.
Select one: I will not be accompanied by a support person. I will be accompanied by:

Set out that person’s name and relationship to you.

Decision:
Select: I have attached a copy of the decision being appealed.

Documentation
Select one: I have no supporting documentation to attach. I have attached a copy of all relevant supporting documentation:

List any additional documents being attached.

1. I have read and I understand Policy 72 – Student Appeals.
2. I certify that any documents I have submitted are authentic and that the statements I have made are true.
3. I may be contacted at the address, telephone number and email address given above.
4. I will immediately report any change to my contact information.
5. I will check my email frequently and respond promptly.

Student’s Signature: _______________________________________________

Date:  ___________________________