Dickinson College Student Health Services
Student Complaint / Grievance Form

Before completing this form, please read the Patients Rights and Responsibilities document and the Complaint / Grievance Procedure located on the Student Health Services web site. After completion,
please return directly to the Director, Student Health Services

Name ______________________________________________________ Class year _______________

Date of incident ____________________________ Current Date _____________________

Please describe the circumstances surrounding the situation, and what your particular grievance is. Please give as much detail as possible.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

_______________________________________ ___________________________________________
Please print name clearly, then sign. Please include your HUB Box. Thank you.