Request for Assistance with Resident Concerns

First name*		Last name*
Phone number*		Room number*(include building)
Mailbox*		E-mail address*

Nature of the concern (include name of person(s) to whom complaint is being made against and all relevant information and details)

What steps have you taken to resolve this situation?(i.e. talked to the person, suite meetings with your RA)

What do you suggest should be done?

The University of Regina collects information under the authority of The University of Regina Act and in accordance with the Local Authority Freedom of Information and Protection of Privacy Act and the Personal Information Protection and Electronic Documents Act for purposes of the administration of the University and its programs and services. By responding to this form, you are consenting to the University of Regina using your personal information (to/for ...describe specific purpose of information gathering on this form).