Shared Governance Council Request Form

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Request Title

Requested By (person or group)

Contact First Name*

Contact Last Name*

Contact Phone*

Contact Email Address*

Rationale: Explain the reason for addressing this issue/problem/concern.

Anticipated Outcomes or Benefits: Describe the overall outcomes or benefits expected.

Primary Stakeholders: Identify the organizational areas (institutional departments, programs, divisions or units) that will most need to be involved in the resolution of this issue.

Secondary stakeholders: Identify other organizational areas that are impacted by this issue

Issue has substantial impact in these areas: (check any that apply)

Cross-function/institutional implications

Policy/procedure implications (Please include number, if known.)

Funding implications

Student impact

Employee impact

Community impact

Other (please specify below)

If Selected: Policy/procedure implications (Please include number, if known.)

If selected : Other (please specify)

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