Quality Assurance Screening Test (QAST) Grievance Form

This form is to be used if you have recently taken the QAST Performance Evaluation, and would like to report any difficulties that you may of encountered during the taking of the Performance Evaluation.

This form will be reviewed by the Director of the Nebraska Commission for the Deaf and Hard of Hearing(NCDHH). A staff member from NCDHH will be in contact with you in a timely manner, regarding your concerns.

Information received from the submission of forms that are posted on the Nebraska Commission for the Deaf and Hard of Hearing (NCDHH) web site, is used for business use only. Information collected through the submission of forms will not be resold for commercial use, all information will be kept confidential.

Entries marked with an * is required information.

Date of Submitting this form: * (month/date/year)

Contact Information

Name: *

Address: *

City: *

State: *

Zip Code: *

Home Phone: * (include area code)

Work/Cell Phone: (include area code)

E-mail Address: *

Grievance Information

Date the QAST Performance Evaluation was taken on: * (month/date/year)

Reason for Grievance Regarding the Videotaping Session: (check all that apply)

Equipment malfunction
Testing material malfunction
Improper Stimuli tape given
Delay in testing time
Improper instructions given
Physical Environment
Other - Description of Other:

Additional Comments:

Reason for Grievance Regarding the Evaluation Score
Comments:

Quality Assurance Screening Test (QAST) Grievance Form

Thank you for your time in completing this form.