Student Complaint/Grievance Form Instructions: A grievance is an educational or personal issue or condition that a student believes to be unfair, inequitable, discriminatory, or a hindrance to his/her education. Students who have a complaint or grievance about their Victor Valley College experience should complete this form and submit it to the Office of the Vice President of Instruction & Student Services located in Building 55 (Counseling and Administration). Students should allow 10 business days to receive a written response to their complaint or grievance. Check one: Complaint (service‐related) Grievance (education‐related) Student Name: Address: Email Address: Semester/Year: Student Information
Student ID#
City/State/Zip:
Best number to be reached at: Current student: Yes No Complaint/Grievance Information
Retaliation against an individual filing a grievance is strictly prohibited and constitutes a violation of college policy which may result in disciplinary action. Name of individual and/or department against whom the complaint/grievance is filed:
Describe your complaint/grievance in detail. Include date/s of occurrence (be as specific as possible). Attach additional sheets, if necessary, along with any documentation that will help describe and substantiate the complaint. Are there any witnesses who should be interviewed? If yes, list names and contact information. Students are encouraged to discuss their concerns and complaints through informal conferences with the appropriate instructor or department. Have you made an attempt to resolve this complaint or grievance with the individual and/or department involved? Yes No If yes, describe the outcome: (Attach any additional comments, if necessary) What outcome do you hope to achieve after talking to the appropriate college official(s): Attach additional sheets, if necessary.
I understand that information contained in the grievance form will be held confidential to the extent possible. Grievance information may be shared with college officials in order to conduct a thorough investigation. I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary actions, in accordance with college disciplinary policies. Signature: Date: Student Approved by Faculty Senate 5/2/13 Grievance flow chart and response to incident Step 1 – Initial Level NOT SATISFIED
Student encouraged to resolve his/her Student must submit a Student Complaint/Grievance Form within 10 days of knowing the decision or action giving rise to the complaint or grievance complaint at the lowest possible level SATISFIED Step 2 – Chairperson/Dean Level If the complaint/grievance is not resolved in Step 1, submit form to appropriate department or program Chair, Director, Coordinator or Dean, if there is no Chair, within 10 working days. SATISFIED Decision within 10 days Complaint/Grievance form must be submitted within 10 days of the date the written Step 2 response was received.
NOT SATISFIED
Step 3 – Dean/VP level
If the complaint/grievance is not resolved in Step 2, submit form to Dean (if the Dean was not involved in Step 2) or Vice President within 10 working days. SATISFIED Decision within 10 days
Complaint/Grievance form must be submitted within 10 days of the date the written Step 3 response was received. NOT SATISFIED
Submission to Supt/President only on the following grounds: Step 4 –Superintendent/President level
If the complaint/grievance is not resolved in Step 3, submit form to Vice President (if Vice President was not involved in Step 3) or Superintendent/President within 10 working days. a) There was a significant lack of due process that deprived you of a fair and equitable result. b) The Step 3 decision is clearly unreasonable or arbitrary. c) There is significant newly discovered information which, in spite of reasonable diligence on your part, could not have been produced earlier. Decision within 10 days is FINAL
For office use only: Action taken by administrator (include Level Two, Three or other documents): Grievance was resolved: Yes No If not resolved, what are the next recommended steps: Administrator signature: Date: