Office of the Vice President of Student Services
1000 W. Foothill Blvd., Glendora, CA 19741-1885 (626) 914-8532, Student Services Building, SS 218
OFFICE USE ONLY:
In favor of student Issue is not grievable
In favor of employee Referred to complaint process
STUDENT GRIEVANCE FORM
Student ID Number: Email:
Mobile Phone: Home Phone:
City: Zip Code:
NOTE: If you have a COMPLAINT that does not fit into either of the categories listed below, please complete the Student Complaint
Please be aware that in order to file a grade grievances, the student must be able to show that it falls
under one of the following categories: Mistake, Fraud, Bad Faith, or Incompetency (California Education Code, Section 76224(a) and
Title 5, Section 55025).
RIGHT TO FREE EXPRESSION GRIEVANCE: The District shall not prohibit the right of students to exercise free expression
including, but not limited to, the use of bulletin boards, the distribution of printed materials or petitions, and the wearing of buttons,
badges, or other insignia, except that expression which is obscene, libelous or slanderous according to current legal standards, or
which so incites students as to create a clear and present danger of the commission of unlawful acts on community college
premises, or the violation of lawful community college regulations, or the substantial disruption of the orderly operation of the
community college, shall be prohibited (California Education Code, Section 76120).
STUDENT SIGNATURE:________________________________________ DATE:
Please follow these steps prior to filing this Grievance:
Step 1: Discuss the incident with the instructor or college employee involved in your grievance
Step 2: If the situation is not resolved after meeting with the college employee then proceed to meet with the employee’s
supervisor or Dean of the Division (for the instructor)
Step 3: If the situation is not resolved after meeting with the supervisor or Dean of the Division, then attach a type-written,
detailed explanation of your grievance to this form. Explain as clearly as possible why you are filing a grievance. Be sure to include
all necessary information (including names, dates, etc.) to support your argument so that an impartial decision can be reached.
Step 4: Submit this completed form to the Office of the Vice President of Student Services. A Grievance Review Board will conduct a
hearing to review this document and make a decision.
Instructor Name: Class:
Term: Fall Winter Spring Summer CRN#
Supervisor Name: Extension: