IMPARTIAL BOARD OF REVIEW (IBR) APPEALS REQUEST FORM

IMPARTIAL BOARD OF REVIEW (IBR)

APPEALS REQUEST FORM

Purpose of this Form:

This form is used to collect details about your request for an Impartial Board Review (IBR). The information you provide helps us decide if your request meets the requirements to set up a review board based on Georgia Tech's policy.

Who Should Fill This Out:

Employees seeking an Impartial Board Review should complete this form only after receiving the outcome of their initial appeal from their department.

Please Note: This must be done within 5 business days of receiving the decision.

How Your Information Will Be Used:

The information you share in this form will be reviewed to confirm it meets the rules in the Impartial Board Review (IBR) policy. All required questions must be answered to successfully complete this form. If your request meets the required standards to proceed, you will be notified about the next steps in the process.

Contact Information

First Name*

Middle Initial

Last Name*

Phone Number*

Email*

Street/Mailing Address*

City*

State/Province*

Zip/Post Code*

Country

What is the best method and time to contact you?

Georgia Tech Employee Details

ID (9 digits)*

Job Title*

Date of Hire*

Department or College*

Select

Admin & Finance

Select

Colleges

Select

Office of the President

Select

Provost & EVP

Select

Research

Select

Appeal Details

Issue Type

Select

Please enter the date that your department told you the result of your first appeal?*

Please attach the determination letter you received.

Drag and drop files here or

Appeal Details and Participants/Witnesses:*

Provide specific details about your appeal, including the names and roles of any participants or witnesses involved.
For each individual, please include their First and Last Name. (If available, you may also provide their Phone Number and Email.)
Share what events or actions they may have observed, along with any supporting documents, timelines, or other evidence that could clarify the situation.

Please Note: The more detailed and precise your information, the better we can evaluate your request and work toward resolving the matter.

Acknowledgement

By selecting "Yes" you certify that the statements and information in this form are, to the best of your knowledge, true, accurate, and complete.*

Yes

Send me a copy of my responses

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