E-55 Form 1
STATEMENT OF GRIEVANCE
Form E-55-1 Ver. 09/07
Student Name SID # College Date
Street Address City State ZIP
Phone Number E-mail
This grievance is being filed under the procedures in LACCD Administrative Regulation E-55 (Student Grievance Procedures). The
purpose of the grievance procedure is to provide a prompt and equitable means for resolving student grievances. A grievance may be
initiated by one or more students who reasonably believe he/she/they have been subject to unjust action or denied rights involving
their status or privileges as students. It is the responsibility of the student(s) to submit proof of alleged unfair or improper action.
Grievances pertaining to grades are subject to California Education Code Section 76224(a).
This grievance procedure does NOT apply to the following: challenges to prerequisites, corequisites, advisories and limitations on
enrollment; alleged violations of sexual harassment; appeals for residency determination; eligibility, disqualification or reinstatement
of financial aid; student discipline, freedom of the press; or employee discipline (see Admin. Reg. E-55 for additional information).
When were you subject to unjust action or denied your rights as a student (i.e., date of incident):
Where were you subject to unjust action or denied your rights as a student:
Name the individual(s) who allegedly took unjust action or denied you your rights involving your status or privileges as student:
State your reason for this grievance:
If this is a grade grievance, have you filed a petition for grade change?
Yes No
If this is a grade grievance, indicate on which ground(s) you believe your grade is incorrect, and explain these grounds below:
mistake fraud bad faith incompetence
(Use additional pages if necessary)
List the policies violated (if applicable):
State the Remedy/corrective action requested:
The College Ombudsperson has informed me of my rights
and responsibilities under Admin. Reg. E-55 and has
provided me with a copy of the regulation.
I have informed the student of his or her rights and
responsibilities under Admin. Reg. E-55 and I have given a
copy of the regulation to the student.
Signature of Student Date Signature of Ombudsperson Date
Copy to Respondent (s)
Date:
