86-200-2

Oglala Lakota College
Informal Student Complaint Form (Exhibit)
(Created May 2012)

Center: _____________________                    Date: _____________________

Nature of complaint: _____________________________________________

______________________________________________________________

______________________________________________________________

Concerning (who/what): __________________________________________

______________________________________________________________

______________________________________________________________

Date (s) of occurrence/event/concern: ______________________________

______________________________________________________________

Action taken: ___________________________________________________

______________________________________________________________

By whom:  _____________________________________________________

When: ________________________________________________________

Outcome (if known): _____________________________________________

______________________________________________________________

______________________________________________________________

Do you want to take this complaint/concern to the formal grievance process?  Y*____ N ____
*If yes, refer to Ruth Cedar Face, EAP/Student Affairs Director at (605) 455-6040

Copies should be placed in every college center, the registrar’s, financial aid, and EAP office.