Student Complaint Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

E-mail

How do you prefer we contact you?

Home PhoneCell PhoneWork PhoneEmail

School or Institution Name*

School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Program

Degree Level

Program Start Date

Program End Date

Current Status*

Currently AttendingGraduatedTerminated/WithdrawnOther

Last Date of Attendence

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?*

YesNo

With whom did you speak about your complaint?*

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

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.*

Signature*

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.

Date*

MonthDayYear

Providing Personal Information Is Voluntary
You do not have to provide the personal information requested. If you do not wish to provide personal information, such as your name, home address, or home telephone, you may remain anonymous. In this case, however, we will not be able to contact you or help you resolve your complaint.

Possible Disclosure of Personal Information
SCHEV will make every effort to protect the personal information you provide us. In order to follow up on your complaint, however, we may need to share the information you give us with the school you complained about or with other governmental agencies. This may include sharing any personal information you gave us.
The information you provide may also be disclosed in the following circumstances:

In response to a public records request, as allowed by the Freedom of Information Act (FOIA),
To another government agency as required by state or federal law, or
In response to court or administrative order, a subpoena, or a search warrant.

Student Information

School Information

Complaint Information

Notice on Collection of Personal Information