Fillable PARTICIPANT COMPLAINT FORM

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PARTICIPANT COMPLAINT FORM

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Revised 8/28/2013
PARTICIPANT COMPLAINT FORM
"PARTICIPANT COMPLAINT AGAINST VENDOR" forms are used to record complaints
by participants against vendors. Complaints are used to identify vendors to be
monitored, with additional training needs, or as a basis for disqualification as a
Muscogee (Creek) Nation-WIC Program authorized vendor. Completed forms may be
mailed to:
Muscogee (Creek) Nation-WIC Program
ATTN: Vendor Coordinator
P.O. Box 580, Okmulgee, Oklahoma 74447
PARTICIPANT COMPLAINT AGAINST VENDOR
PROBLEM: (Include Vendor Employee Name/Physical Description) _______________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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PARTICIPANT SIGNATURE: ________________________________________________
STORE NAME & LOCATION: ________________________________________________
COMPLAINT RECEIVED BY: ________________________________________________
DATE COMPLAINT WAS RECEIVED: ______________________________________ __
PARTICIPANT NAME(S) WILL NOT BE DISCLOSED DURING THE HANDLING OF
THIS COMPLAINT.
“This Institution Is An Equal Opportunity Provider”
Revised 8/28/2013
PARTICIPANT COMPLAINT AGAINST VENDOR - SIDE 2
THIS SECTION TO BE COMPLETED BY MUSCOGEE (CREEK) NATION-WIC EMPLOYEE
ACTION TAKEN: __________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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__________________________________________________________________________
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SIGNATURE: ___________________________________________________
DATE: _________________________________________________________
TITLE: _________________________________________________________
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PARTICIPANT COMPLAINT FORM

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Completed 1 February 2022

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