Grambling State University
Division of Student Affairs - ADA Student Services


Information contained in this compliant form is confidential and should only be reviewed by those who have a need to know. If at any time the complainant feel that he/she is adversely targeted because of filing this complaint, the complainant should consult immediately with the University EEO Officer.

The Complainant should receive a response to the complaint within five (5) full working days of submitting the complaint. If the decision is delayed because of a need for a more thorough investigation, the complainant should be notified and a new response date will be identified.

Name of Complainant Social Security Number
On Campus Address Telephone Number
Home Address Home Telephone Number
Basis for the Complaint
Explain thoroughly, the concerns/issues that you want addressed. (Use the reverse side of this form and additional paper if needed).

What have you done and to whom have you spoken to in order to try and resolve this issue?

If a determination is made that interviews are needed, suggest the names, addresses and telephone numbers of those you feel should be interviewed and why.

What do you suggest as a reasonable, satisfactory response to your concerns/issues?


___________________________      ________________________________    __________________
Name (Please Print)                                                                 Signature                                                                 Date