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.

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Student's Full Name

Phone Number

Core / Specialties

Electives

Rotation Start Date:

Rotation End Date:

Date of Incident

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