Office of the Vice President of Student Services
1000 W. Foothill Blvd., Glendora, CA 19741-1885 (626) 914-8532, Student Services Building, SS 218
STUDENT COMPLAINT FORM
Student Name: ____________________________________________________________________________
Student ID Number: __________________________________ Email: __________________________________
Mobile Phone: __________________________________ Home Phone: ___________________________
Street Address: __________________________________
City: __________________________________ Zip Code: ______________________________
NOTE: If you have a complaint relating to course grades or the right to free expression, please complete the Student Grievance
Form.
Please explain below or attach a type-written, detailed explanation of your complaint. Explain as clearly as possible why
you are filing a complaint. Be sure to include all the necessary information (including names, dates, etc.) to support your
statements so that your complaint can be appropriately addressed. Please complete and submit this form to the office
or department where the incident occurred.
Please type the name of the employee that is involved in your complaint (if applicable):
Employee Name: __________________________________ Date of Incident: ________________________
Department/Office: ________________________ Department Phone: _____________________
Desired Outcome
STUDENT SIGNATURE:________________________________________ DATE: ___
_____________________
Office of the Vice President of Student Services
1000 W. Foothill Blvd., Glendora, CA 19741-1885 (626) 914-8532, Student Services Building, SS 218
FIRST LEVEL FOR OFFICE USE ONLY
Date Received: ________________________
Result/Outcome:
Informal resolution, met with student
Forwarded to instructor for resolution
Student did not request action, just be heard
Complaint involved grades and/or freedom of expression. Student was directed to follow the Grievance process.
Complaint involved sexual, harassment, discrimination, violence, or stalking and was forwarded to the Title IX
Coordinator in Human Resources on:
Other (explain):
Manager Name: ________________________ Extension: ________________________
Signature: ___________________________________________ Date: ________________________
IF necessary, forward information to second level administrator (i.e. Dean or Vice President)
SECOND LEVEL FOR OFFICE USE ONLY
Date Received: ________________________
Result/Outcome:
Name: ________________________ Extension: ________________________
Signature: ___________________________________________ Date: ________________________
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