COMPLAINT SUBMISSION FORM
Formal Resolution

This form is for submitting a complaint for formal resolution by the University.  It should only be submitted after a person has attempted to informally resolve their complaint; or where informal resolution is not possible or appropriate.  
This form must be submitted to the Complaint Resolution Unit by email to complaints@uwa.edu.au or by mail to mailbag M456A, 35 Stirling Highway, Crawley, Western Australia 6009.
This form must not be used for making a public interest disclosure.  Refer to www.complaints.uwa.edu.au or contact the Complaint Resolution Unit for more information.
A Informal resolution
Choose the relevant option and provide more information below.
☐  I have not been able to resolve my complaint informally 
☐	I have not attempted to resolve my complaint informally because I believe my complaint raises a serious matter suitable for formal resolution; and/or I have valid reasons for not attempting informal resolution 

	

B Contact information
Are you submitting this complaint on behalf of someone else? If no, complete Section 1 only.  If yes, complete both sections, placing your details in Section 1.  If you are submitting a complaint on behalf of someone else, you must obtain their authority for you to act on their behalf.  A form for this purpose is available at http://www.student.uwa.edu.au/life/complaints/submit. 
Section 1	Section 2	
☐  Student        ☐  Staff       ☐  Community       ☐  Other	☐  Student        ☐  Staff       ☐  Community       ☐  Other	
ID:		Title:		ID:		Title:		
Surname:		Surname:		
First name:		First name:		
Street/PO:		Street/PO:		
Suburb:		Postcode:		Suburb:		Postcode:		
Tel:		Tel:	
Email:		Email:		
C Respondent details (if applicable)
If your complaint is against a person, please complete the applicable fields below, if known.	
☐  A student
☐  A community member	☐	A professional staff member
☐	An academic staff member	
Surname:		First name:		
Other:		
D Complaint category
☐  General Administration & Service	☐  Corporate Governance (how and what we do)	
☐  Physical Environment (facilities/venues/grounds)	☐  Education Provision (teaching/supervision)	
☐  Student Administration (service/non-academic matters)	☐  Staff Administration (conditions/entitlements)	
☐  Conduct (conduct of staff/students/community members)	☐  Not sure	
E Complaint details
Provide a summary of your complaint below.  Include details such as the location, date, time, names of any people or areas of the University involved.  Please indicate if you have provided additional documentation.
☐  I have attached documents that provide additional details
☐  I have not attached documents that provide additional details

	
F Outcomes sought
State the outcomes you are seeking from the complaint process, e.g. an apology from the respondent, a change of decision, etc.  

	
G Other (optional)
Please provide any additional information that may assist the University to resolve your complaint.
	
H Complainant declaration
In submitting this complaint, I confirm that:
☐  the information I have provided on this form is correct to the best of my knowledge;
☐  I intend to cooperate in good faith, act in accordance with the UWA Code of Ethics and Code of Conduct, respect confidentiality of the process and immediately disclose any actual, perceived or potential conflict of interest to the Responsible Officer for the complaint as part of my involvement in the complaint process; and
☐  I understand that the information I provide will be treated confidentially and will not be disclosed to a third party   unless required.

Complaint Resolution Unit use only 
Date received: ____/____/____  Date acknowledged: ____/____/____  TRIM File: ____________  CHS Ref.: _________________