(To be completed for each course reported. Please maintain confidentiality.)
Course Name: [Enter Course Name]
Course Number: [Enter Course Number]
Section: [Enter Section]
Course Title: [Enter Course Title]
Term: [Enter Term]
Providing College: [Enter Providing College]
Instructor: [Enter Instructor Name]
Host College: [Enter Host College]
Receiving Individual: [Enter Receiving Individual]
Student Information:
Student Name | Student ID | Incorrect Grade or Status/LDA | Correct Grade |
Reason for Grade Change:
[Enter Reason for Grade Change]
Submit by email to the Chief eLearning Officer (CELO). CELO will disseminate to student's Host College and/or process.
Miss. Code. tit. 9, pt. 8, app 9-8-G