Complaint Form

UW System Institution *

Complainant Name *

First Last

Complainant Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Complainant Phone *

Complainant Email *

Enter Email Confirm Email

If you are not the complainant, but are submitting this form on their behalf, please also answer the following:

Other - Name

First Last

Other - Phone

Other - Email

If you are a Former Student, please provide your last date of attendance:

MM

DD

YYYY

Date complaint was filed with the Institution: *

MM

DD

YYYY

Name of person at institution who handled the complaint (if known)

First Last

Email address of person at institution who handled the complaint (if known)

Status of Complaint *

Details of Complaint: *

Please include all names, dates, locations pertinent to our understanding of the situation.

Resolution: *

What resolution or outcome are you seeking in the filing of this complaint?

In order for this complaint to be processed, please read and affirm (by clicking the check box) all of the following: *

I hereby attest that the above information is true and accurate to the best of my knowledge. I will provide additional information and supporting documentation upon request.
I hereby authorize the UW System and/or any of its representatives, to disclose the information submitted to the campus/campus officials against which the complaint is filed.
I understand that UW System may dismiss the complaint if an investigation determines that the complaint is without merit.
I hereby affirm that I have executed this form either on my own behalf OR on behalf of the complainant for the specific purposes I describe.

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