STUDENT COMPLAINT FORM

STUDENT COMPLAINT FORM
Student Information
Full Name
Address
City
State
Home Phone Number
Work Phone Number
Cell Phone Number
Email
Zip
How do you prefer we contact you?
home
work
School Name
cell
email
School Information
School Address
School City
State
Zip
Complaint Information
1. Did you follow the school’s grievance procedure to resolve your complaint with the school?
Yes
No
Who did you contact? (list all with names and titles)
2. Have you filed this complaint with another organization?
Organization’s Name:
3. Do you have an attorney?
No
Yes
Yes
No
Name:
4. Please attach a statement describing the nature of the complaint. The statement
should include a description of the events or circumstances upon which the
complaint is based and all supporting documentation for your complaint must be
attached. Specify any pertinent dates, staff you dealt with, monies owed,
balances due, etc.
The information you provide will be used in efforts to resolve your complaint and will be shared
with the school. By submitting this complaint and the accompanying FERPA Consent and
Release Form, you are giving the West Virginia Council for Community and Technical College
Education or West Virginia Higher Education Policy Commission permission to contact school
officials to discuss a possible resolution to your complaint.
Signature:____________________________________
Date:______________
STATE OF ________________
COUNTY OF _______________
I, ____________________________________ a notary public in and for said state do hereby
certify that _____________________________, whose name is signed to the writing above,
has this day acknowledged the same before me.
Given under my hand this _____ day of _______________, ____
My Commission expires _____________________________
__________________________________________________
Notary Public
Council/Commission Use Only:
Date Received:
CCTCE Jurisdiction?
HEPC Jurisdiction?
□Yes □No
□Yes □No
Classification of Complaint:
□Ac □Adm □Fin □FA □Oth
Mail or Fax all complaints with associated documents to:
Executive Vice Chancellor for Administration
West Virginia Council for Community and Technical College Education
West Virginia Higher Education Policy Commission
1018 Kanawha Boulevard, East
Suite 700
Charleston, WV 25301
Fax: 304.558.5719
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