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Student Complaint Intake Form_15NOV2012 (2)

Student Complaint Intake Form_15NOV2012 (2)

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Published by Barmak Nassirian

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Published by: Barmak Nassirian on Jan 03, 2013
Copyright:Attribution Non-commercial

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01/03/2013

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SAMPLE COMPLAINT INTAKE FORM:
(* = required inputs)
1. Education Benefits Currently Using?*
(check all that apply)
 
Military Tuition Assistance (Title 10 Funding )
o
 
Tuition Assistance (TA) for Active Duty Service members or Reserve Componentpersonnel in an active drilling status
o
 
Tuition Assistance (TA) for Service members performing Active Guard and Reserve (AGR)duties
o
 
Military Spouse Career Advancement Accounts (MyCAA)
 
GI Bill
o
 
Post-9/11 (CH 33)
o
 
Montgomery (MGIB: CH 30)
o
 
Reserve Educational Assistance Program (REAP: CH 1607)
o
 
Select Reserve (SR: CH 1606)
o
 
Survivors & Dependents Assistance (DEA: CH 35)
o
 
Vocational Rehabilitation and Employment (VR&E: CH 31)
o
 
Veterans Retraining Assistance Program (VRAP)
o
 
Tuition Assistance Top-Up
 
Federal Financial Aid (e.g., Federal Pell Grants, Federal Stafford Loans, Federal Perkins Loans andPLUS Loans)
 
Unsure
2. School Information?*
 
School Name [LOOKUP: Name, Address, City, State, Zip, Country, Generic schools namesavailable for online school, campus sites or DL email]
 
Level of study [Drop down menu]
o
 
Certificate/Diploma
o
 
Associate
o
 
Bachelor
o
 
Graduate/Professional
 
Total amount of tuition you paid “out-of-pocket” in the last academic year? $____________
 
Total amount of tuition paid by any government benefit in the last academic year? $_________
3. Which best describes your issue?*
(check all that apply)
 
 
Recruiting/Marketing Practices
 
Student Loans
 
Quality of Education
 
Transfer of Credits
 
Accreditation
 
Post-graduation job opportunities
 
Grades
 
Refund Issues
 
Financial allegation
 
Change in degree plan/requirements
 
Release of Transcripts
 
Other
 
 
4. Describe what happened so we can understand the issue.*
[TEXT BOX]
5. What do you think would be a fair resolution to your issue?
[TEXT BOX]
6. Student is a:
 
Service member
o
 
Active Duty
o
 
Reserves
o
 
National Guard
 
Spouse or Family Member
 
Veteran
7. Branch:
[Veteran/Service member select one; Military spouse select Service member’s Branch]
 
 
Army
 
 
Navy
 
 
Air Force
 
 
Marines
 
 
Coast Guard
 
NOAA (National Oceanic and Atmospheric Administration)/PHS (Public Health Service)8.
I am filing on behalf of 
 
Myself 
 
 
Someone else
 
9.
Preferred Contact Information
 
 
Salutation (w/military ranks):
o
 
E-1
o
 
E-2
o
 
E-3
o
 
E-4
o
 
E-5
o
 
E-6
o
 
E-7
o
 
E-8
o
 
E-9
o
 
W-1
o
 
W-2
o
 
W-3
o
 
W-4
o
 
W-5
o
 
O-1
o
 
O-2
o
 
O-3
o
 
O-4
o
 
O-5
o
 
O-6
o
 
O-7
o
 
O-8
o
 
O-9
o
 
O-10

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