GF-E - COMPLAINT: MEMBER OF THE GENERAL PUBLIC

This form is used both for an initial complaint/grievance and for an appeal of a complaint decision. If you are filing an initial complaint, please complete #'s 1 through 4, below. If you are appealing a complaint decision, please complete #'s 1 and 5, below.

Please attach additional pages if necessary.

1. Name:
2. Please state the date of the event or series of events causing the complaint:
3. Please state your complaint, including relevant and specific supporting facts, including how you believe the action(s) you are complaining about was/is harmful to you:
4. Please state the specific remedy you are seeking; including a request for what you want to happen:
5. I am appealing the following decision:

Name of Administrator Making Decision:

Date Decision Received:

Reason you believe the decision should be changed or amended:

__________________________________________________________________________

Signature of Person Filing Complaint or Appeal                                               Date

Adopted: 1/26/07

Amended:

Reviewed:

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