COMPLAINT FORM (Concerning Medical Schools)

University Named in the Complaint

Name

First

Last

Address

Email

Phone

Gender

Male

Female

Other

Status in relation to the institution named in the complaint (Select all that apply).

If other please specify

Complaint Date

Complaint Taken by

Complaint Details: (Briefly describe the details of the complaint) State the general nature of your complaint as clearly and concisely as possible. This statement helps GMDC determine if the complaint falls within the scope of the GMDC complaint policy.

Link to Standard: Which of the GMDC’s Accreditation Standards Theme does your complaint refer to? Identify the specific standard or element. (Select all that apply)

First Response Corrective Action: (List the steps you have taken to resolve the complaint, including demonstrating your serious effort to follow the institution's grievance or complaint procedures. Explain any other external channels that you are pursuing to resolve the complaint.)

Please Provide any additional comments you wish GMDC to consider when investigating the complaints:

By submitting this form, I understand that I am granting GMDC the permission to share my complaint and any supporting documentation with the relevant authority to which the complaint is related.

Name of Person Completing this form

Signature

Date