Please note that this form is for students to file a complaint about an instructor. Students wishing to file a grade grievance should consult the Current Students Page on the LAVC website.

* 1. Prior to filing this complaint, students are required to first meet with instructor and then that instructor's department chair. Have you done so?

* 2. Your Full Name

* 3. Your Student ID Number:

* 4. Please provide your phone number:

* 5. Please provide your email.

* 6. Please provide the name of the department, class, and/or instructor that is the subject of your complaint.

* 7. Please provide a detailed description of your complaint. If it is an incident, please include the date, time and place as well as any witnesses who were present.

* 8. What action or remedy do you request for your complaint?

Thank you for completing this form. You will be contacted within ten working days.