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.

* 1. Please enter your first and last name

* 2. Address

* 3. Home Phone including area code

* 4. Cell Phone including area code

* 5. Work Phone including area code

* 6. Email Address

* 7. How do you prefer we contact you?

* 8. School or Institution Name

* 9. School Address

* 10. Name of Program

* 11. Degree Level

* 12. Program Start Date

* 13. Program End Date

* 14. Current Status

* 15. As required by law, SCHEV cannot respond to complaints until the student has exhausted all grievance procedures provided by the school. Please refer to your school's Student Handbook for specific details on this process before submitting this form. Did you follow the school's grievance procedure to resolve your complaint with the school?

* 16. With whom did you speak about your complaint?

* 17. Describe your complaint in detail. Specify any pertinent dates, staff you dealt with, monies owed, balances due etc.

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

* 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.

* 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.

* 21. Todays date

Date / Time
/
/

T