PRINCIPLES OF EXCELLENCE COMPLAINT

INTAKE QUESTIONNAIRE  IMPORTANT:  (*) indicates required input.

DATE RECEIVED (For VA use only)

1. EDUCATION BENEFITS USED? * (Check all that apply)

VA  FORM MAR 2013 22-0959 Page 1

GI BILL

Post-9/11 (CH 33)

Montgomery (MGIB: CH 30)

Reserve Educational Assistance Program (REAP: CH 1607)

Selected Reserve (SR: CH 1606)

Survivors & Dependents (DEA: CH 35)

Vocational Rehabilitation & Employment (VR&E: CH 31)

2. SCHOOL INFORMATION? *

Veterans Retraining Assistance Program (VRAP)

Tuition Assistance Top-up

MILITARY TUITION ASSISTANCE (Title 10)

Federal Tuition Assistance (TA)

State Funded Tuition Assistance (National Guard)

Military Spouse Career Advancement Accounts (MyCAA)

FEDERAL FINANCIAL AID (e.g., Pell Grant and Federal Student Loans)

Level of study

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

Tuition/fee charges

Sudden change in degree plan/requirements

Release of Transcripts

Other (specify)

Total amount of tuition paid by you or any government benefit in the last academic year: $________________________

NAME OF SCHOOL:__________________________________________

ADDRESS OF SCHOOL:__________________________________________

CITY:_______________ STATE:_______________ ZIP Code:_____________ COUNTRY:____________

Total amount of of tuition you paid "out of pocket" in the last academic year: $________________________

OMB Control No. XXXX-XXXX Respondent Burden: 20 minutes

NOTE:  PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON PAGE 2 BEFORE COMPLETING FORM.

FOR VA USE ONLY ACCEPTED BY: NAME AND TITLE OF EDUCATION CENTER OFFICIAL DATE SIGNED  Telephone No. (Include Area Code)

VA FORM 22-0959, MAR 2013 Page 2

5. WHAT DO YOU THINK WOULD BE A FAIR RESOLUTION TO YOUR ISSUE:

6. YOU ARE A: (Check all that apply)

Veteran

Servicemember

Spouse or Family Member

7. BRANCH OF SERVICE: (Check one)

Army

Navy

Air Force

Marines

Coast Guard

NOAA/PHS

8. I AM FILING ON BEHALF OF:

Myself

Someone else

9. PREFERRED CONTACT INFORMATION (Optional):

Provide your first, middle, last name:__________________________________________________

Provide complete address (number, street, city, state, zip and country):____________________________________________________________

Provide your phone number (include area code):___________________________

Provide your e-mail address:_________________________________

Provide your age:___________

4. DESCRIBE WHAT HAPPENED SO WE CAN UNDERSTAND THE ISSUE:

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38, Code of Federal Regulations, section 1.576 for routine uses as identified in the VA system of records, Principles of Excellence Centralized Complaint System-VA (170VA22), published in the Federal Register. Information collected on this form serves as a record of the complaint, and is used for collecting complaint data; responding to or referring the complaint; aggregating data that will be used to inform other functions of VA and, as appropriate, other agencies and/or the public; and preparing reports as required by law. Your response is voluntary. RESPONDENT BURDEN: We need this form in order to receive, respond to, and refer complaints regarding VA educational assistance benefits. This information can only be obtained from the individual respondent. Executive Order 13607 allows us to ask for this information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.