Resident Grievance Form
All grievances are sent directly to the recipient of your choice and are anonymous unless the complainant wishes to include their name.
Please choose whom you would like your grievance form sent to:
Steve Arnold, Chief Compliance Officer
Tyler Elam DO, Founding Program Director LCPCC Family Medicine Residency Program
Wade Rankin DO, Associate Program Director LCPCC Family Medicine Residency Program
Kara Walters, Designated Institutional Official
Date
-
Month
-
Day
Year
Date
Employee Name (optional)
First Name
Last Name
Job Title (optional)
Email (optional)
example@example.com
Details of Event Leading Grievance
Date and Time of Event
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Event
Account of Event
*
Please provide a detailed information. Include the names of all persons involved.
Violations
Attach additional documents if needed
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