Complaints and Grievances Form

COMPLAINANT INFORMATION

COMPLAINT DESCRIPTION

Compliance/Quality Improvement Committee

Finance Comm. Mtg.

COMPLAINANT INFORMATION

COMPLAINT DESCRIPTION

CFCHS’ reporting systems are intended to assist in resolving issues and improving services. While anonymous complaints are welcome, please understand that a lack of contact and sufficient, specific and accurate information may impede CFCHS’ ability to thoroughly investigate the allegations. Failure to provide contact information will hinder our ability to contact you about the actions taken regarding the complaint.

Pursuant to F.S 784.048(2), A person who willfully, maliciously, and repeatedly follows, harasses, or cyberstalks another person commits the offense of stalking, a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

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:

DAYTIME PHONE:

PROVIDER INFORMATION*

Provider Name

*

Program Name

ADDRESS:

Street Address Address Line 2 City State ZIP Code

PROVIDER PHONE:

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?*

(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.

If you have evidence, please attach documents.

If not, where/how can we obtain evidence of this event?

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.*

What type of resolution will be satisfactory to you?*

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

« April 2019 »

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