Student Complaint Form

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Fields marked with * are required.
Type of Complaint*
Site Complaint Pertains to*
- Illinois
- Florida
Contact Information
Name*
Phone*
Email
Address
Street Address City State Zip
If you are not completing this form on your own behalf, please provide the identity and contact information for the person whom you believe has a concern.
Complaint Details
Have you brought this matter to the attention of any other department(s) at NUHS? If so, please list the name(s) and department(s) of all other persons with whom you have discussed the matter.*
Please tell us as much as you can in your words; include all facts you believe are relevant including what, when, where, and who was involved. Be specific about dates, departments, college officials, facility, time, procedures, and/or class.*
Name of person or persons you are concerned with and why you have contact with them, e.g. college officials, co-worker, faculty, student, patient, or client.*
Describe the corrective action you are seeking.*
For retaliation complaints, please explain why you believe you are being retaliated against.
Witnesses (name, relationship to you, and phone number)
Consent*
By checking this box, I affirm that the above grievance is true to the best of my knowledge and information.*
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