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

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* 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?

Your Full Name

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* 2. Your Full Name

Your Student ID Number:

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* 3. Your Student ID Number:

Please provide your phone number:

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* 4. Please provide your phone number:

Please provide your email.

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* 5. Please provide your email.

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

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

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.

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* 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.

What action or remedy do you request for your complaint?

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* 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.

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