Request for Academic Appeal

Request for Academic Appeal
Use this form to request a review of an academic decision that you were unable to resolve with your instructor. This form will be sent to a dean who will review the facts of the situation and make a determination regarding its outcome. This form may also be used a second time to request a review of a dean’s decision by the Academic Appeals Committee.
Please select the type of academic appeal that you are requesting. If you are requesting an appeal for both an academic integrity violation and a final grade, check both boxes.
FINAL GRADE APPEALS ONLY: Justification for a grade change may include the following criteria. Please check the boxes for the criteria that apply to you.
Today's Date

MonthDayYear
Name

First NameLast Name
FCC Student ID #
FCC Email Address
@myfcc.frederick.edu
You must use your FCC email address to submit this request.
Course #
Section
Title
Name of Instructor
Email of Instructor
example@example.com
Semester Enrolled
Year Enrolled
School/Community
AVP Dean Email
example@example.com
Date of original meeting (or email) with instructor to informally resolve issue

MonthDayYear
Please submit any written correspondence you had with your instructor regarding this issue. This includes your complaint and the instructor’s response. You can upload multiple files below.

Example: Syllabus, email exchange, screen shots, relevant documentation
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In the box below, explain your rationale for appealing the instructor’s decision. Your statement should clearly explain the circumstances that affected your academic performance or situation. Be factual, specific, and concise. Please avoid submitting confidential information that is not necessary for the review of your appeal.
Submit any additional documentation you have to support your request. You can upload multiple files below.

Example: Syllabus, email exchange, screen shots, relevant documentation
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After your appeal is submitted, the appropriate reviewer will evaluate your request. You may be contacted for additional information, documentation, or to schedule an Academic Appeal hearing.

All communication regarding your appeal will be sent to your FCC email address. Be sure to check your FCC email regularly throughout this process.

Students are expected to continue meeting all applicable academic and financial obligations while the appeal is under review.
Signature of Student
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AVP/Dean or Assistant Dean Response
Outcome
Name of Reviewer (Dean or Assistant Dean)
Notes (findings, proposed resolution, outcome):
Attach all relative information, i.e. grade center, syllabus, email exchange, and any other information used to make your recommendation.

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AVP/Dean or Assistant Dean Signature
Date of Signature/Response Sent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Appeal to Committee

In accordance with the Complaint Policy and Procedures for Students, if you reasonably believe the final course grade issue was not resolved, you may file an appeal with the Grade Grievance Committee within five (5) workdays of the original response.
I wish to appeal
Response Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMust be filed within five (5) workdays of of the response date.
Date Filing Appeal

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Comments
Attach additional files to present to the Appeals Committee

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Signature of Student
Office of the Provost

Appeal to Committee
Date of Decision

MonthDayYear
Comments (optional)
Committee Letter

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Additional Files

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Submit Final Documents?
Frederick Community College
7932 Opossumtown Pike • Frederick, MD 21702
301.846.2400 • frederick.edu

Frederick Community College (FCC) prohibits discrimination against any person on the basis of age, ancestry, citizenship status, color, creed, ethnicity, gender identity and expression, genetic information, marital status, mental or physical disability, national origin, race, religious affiliation, sex, sexual orientation, or veteran status in its activities, admissions, educational programs, and employment. Under the ADA and Section 504, FCC makes every effort to accommodate individuals with disabilities for College-sponsored events and programs. For FCC employees needing accommodations, including interpreting, email humanresources@frederick.edu. For students and others with accommodation needs or questions, call 301-846-2408, or to request sign language interpreter services, please email interpreting@frederick.edu. Sign language interpreters will not be automatically provided for College-sponsored events without a request for services. Requests must be made at least five workdays before a scheduled event to guarantee accommodations. If your request pertains to accessible transportation for a College-sponsored trip, please submit your request at least 21 calendar days in advance. Requests made less than 21 calendar days in advance may not be able to be guaranteed.
frederick.edu/accommodations
Should be Empty:

Request for Academic Appeal

AVP/Dean or Assistant Dean Response

Student Appeal to Committee

Office of the Provost