Complaints/Concerns Form - Center for Haitian Studies, Inc.

CHS/GMHETC COMPLAINT/CONCERN FORM

Any and all complaints/concerns from students participating in clerkship rotations under GMHETC must be submitted using this form in order for such complaints/concerns to be reviewed by GMHETC Special Staff Panel. This applies even if the complaint/concern was also submitted via e-mail and/or verbally.

STUDENT'S FULL NAME (*)

Please enter your full name.

PHONE NUMBER(*)

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E-MAIL ADDRESS(*)

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CORES / SPECIALTIES

ELECTIVES

ROTATION START DATE

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ROTATION END DATE

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DATE OF COMPLAINT / CONCERN / INCIDENT(*)

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Please make the selection that best describes the nature of your concern, complaint or request. (Note that this form must be filled for each complaint/concern/incident separately)

SPECIFIC COMPLAINT/CONCERN/REQUEST(*)