Complaints and Grievances Form

COMPLAINANT INFORMATION

COMPLAINT DESCRIPTION

Compliance/Quality Improvement Committee

COMPLAINANT INFORMATION

COMPLAINT DESCRIPTION

Fields with * are required. If you do not have the information, please write "N/A" or "Unknown".

Would you like to be contacted?*

Yes
No

If you selected yes, then please provide your information:

NAME:

First Last

E-MAIL ADDRESS:

ADDRESS:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DAYTIME PHONE:

PROVIDER INFORMATION*

Provider Name

"*

Program Name

ADDRESS:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PROVIDER PHONE:

STAFF INVOLVED*

(Be specific. Please avoid statements such as "everyone in the agency", "all supervisors", "leadership and management"). Include names and last names of staff involved and their titles.

COMPLAINT SOURCE*

TYPE OF COMPLAINT*

ACCESS TO CARE
TREATMENT
CIVIL RIGHTS AND AUXILIARY AIDS SERVICES

What happened?*

When did it happen (date and time of event)?*

Where did it happen (location of event)?*

Who was involved?*

Have you tried to solve this issue with the agency? If so, please provide names and titles of staff working to solve the issue, and their proposed resolution.*

Name of any other agencies contacted regarding this issue (Law Enforcement, Abuse Hotline, Inspector General, etc.)*

« April 2018 »

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