San Joaquin Delta College s2

Request for Grievance Hearing - FORM 5540

For grievances/complaints, including academic grade disputes, student(s) must complete Form 5535 Grievance Mediation Form and attempt to discuss the matter with the professor/faculty, administrator, or other staff of the District, or with the person’s immediate supervisor, usually a Dean, before requesting a grievance hearing on the matter. If the student fails to file Form 5535 in a timely manner, the student shall be precluded from pursuing a formal resolution of the grievance as provided in AP 5530.

Student Last Name First Name Delta ID# Date

Mailing Address Phone Number Cell Phone Number Email

I.  Identify Reason for Grievance Hearing: (See AP 5530)

A. Violation of the rights of free expression protected by state and federal constitutions and Education Code EC 76120.

B. Infringement of any right specifically granted to the student by a duly established District rule or regulation.

C. Course Grade Dispute due to: Mistake; Fraud; Bad Faith; Incompetence [EC 76224(a)]

Relief Sought by Student: (Provide evidence. If necessary, attach second sheet.)

II.  Informal attempts to resolve: Describe attempts to resolve this issue informally. Include names and dates and related documentation.

III.  Describe outcome of informal attempt to resolve:

For A. and B., above, submit this form to the District’s Hearing Officer, DeRicco Student Services Center, Office of the Dean of Counseling and Special Services, Room 234.

For C., above, issues related to course grades, submit this form to the Division Dean who oversees the subject area of the course. For example, ENGLISH: Submit to the Division Dean who oversees the subject of English.

Signature of Student: Date:

THIS SECTION FOR OFFICIAL USE ONLY

q  The grievance is filed in a timely manner. Y/N

q  The student wants to dispute a course grade received due to: Mistake, Fraud, Bad Faith, or Incompetence Y/N

q  The statement contains facts which, if true, would constitute a grievance under these procedures. Y/N

q  The grievant is a student as defined in these procedures, which include applicants & former students. Y/N

q  The grievance is not without foundation or filed for purposes of harassment. Y/N

q  Based on the type of grievance, if criteria are satisfied, the Hearing Officer or ASVPI/designee shall schedule a hearing.

Signature/Title: Date

Hearing Officer or Assistant Superintendent/Vice President of Instruction/Designee

q  Hearing Date: ______Time:

q  Hearing Panel Recommendation: Approved Denied Other

q  Comments:______

AP 5530 Student Rights, Grievances & Grade Disputes

Form 5535 Grievance Mediation Form

Form 5540 - Request for Grievance Hearing Form (June 2014)