Student Complaint Form

BEFORE PROCEEDING, PLEASE VERIFY THAT

You have exhausted all available grievance procedures established by the institution; and

You are not satisfied with the resolution provided by the institution and are contacting SCHEV as a last resort in the grievance process.

Please enter your first and last name

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* 1. Please enter your first and last name

Address

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* 2. Address

Home Phone including area code

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* 3. Home Phone including area code

Cell Phone including area code

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* 4. Cell Phone including area code

Work Phone including area code

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* 5. Work Phone including area code

Email Address

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* 6. Email Address

How do you prefer we contact you?

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* 7. How do you prefer we contact you?

School or Institution Name

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* 8. School or Institution Name

School Address

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* 9. School Address

Name of Your Academic Program

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* 10. Name of Your Academic Program

Degree Level

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* 11. Degree Level

Program Start Date

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* 12. Program Start Date

Program End Date

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* 13. Program End Date

Current Status

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* 14. Current Status

Did the institutional complaint process conclude with a member of the administration providing a written document stating the decision is final, or without the possibility of appeal? 

If not, consult the institution’s grievance policy and complete that process before submitting this form.  As required by law, SCHEV cannot intercede until you have exhausted the institutional process. 

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* 15. Did the institutional complaint process conclude with a member of the administration providing a written document stating the decision is final, or without the possibility of appeal? 

If not, consult the institution’s grievance policy and complete that process before submitting this form.  As required by law, SCHEV cannot intercede until you have exhausted the institutional process. 

By position title with whom did you speak about your complaint? (e.g. Director of Financial Aid, Dean of Arts and Sciences)

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* 16. By position title with whom did you speak about your complaint? (e.g. Director of Financial Aid, Dean of Arts and Sciences)

Describe your complaint in detail. Identify the school policies involved and specify any pertinent dates, staff you dealt with, monies owed, balances due etc.

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* 17. Describe your complaint in detail. Identify the school policies involved and specify any pertinent dates, staff you dealt with, monies owed, balances due etc.

How would you like to see your complaint resolved?

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* 18. How would you like to see your complaint resolved?

THE FILING OF THIS COMPLAINT DOES NOT PROHIBIT YOU FROM CONCURRENTLY FILING A CIVIL ACTION AND DOES NOT AFFECT YOUR REPAYMENT OBLIGATION UNDER ANY STUDENT LOAN AGREEMENT. I HEREBY CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE COMMONWEALTH OF VIRGINIA THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE STATEMENTS ARE TRUE AND CORRECT. I FURTHER AUTHORIZE THE STATE COUNCIL OF HIGHER EDUCATION FOR VIRGINIA AND ITS OFFICIAL REPRESENTATIVES TO ACCESS MY STUDENT RECORDS. PLEASE INITIAL IN THE BOX BELOW THAT YOU HAVE READ THIS DISCLOSURE.

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* 19. THE FILING OF THIS COMPLAINT DOES NOT PROHIBIT YOU FROM CONCURRENTLY FILING A CIVIL ACTION AND DOES NOT AFFECT YOUR REPAYMENT OBLIGATION UNDER ANY STUDENT LOAN AGREEMENT. I HEREBY CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE COMMONWEALTH OF VIRGINIA THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE STATEMENTS ARE TRUE AND CORRECT. I FURTHER AUTHORIZE THE STATE COUNCIL OF HIGHER EDUCATION FOR VIRGINIA AND ITS OFFICIAL REPRESENTATIVES TO ACCESS MY STUDENT RECORDS. PLEASE INITIAL IN THE BOX BELOW THAT YOU HAVE READ THIS DISCLOSURE.

Please type your signature in the box below.

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* 20. Please type your signature in the box below.

Pursuant to Va. Code Ann. 59.1-496, a typed signature above serves as an electronic signature and will be accepted as a valid and binding signature.
Todays date

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* 21. Todays date

Date / Time

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