Client Grievance Form
In accordance with our Client Grievance Policy, all persons receiving services, directly or
indirectly, from DHHSC, have the right to file a grievance for unsatisfactory services
rendered. In an effort to address and respond to your specific concern, please complete
the following information as thoroughly as possible.
Sign in to Google to save your progress. Learn more
Email *
Your name *
Address *
Phone number *
Date Grievance form filled out *
MM
/
DD
/
YYYY
Have you read and understand our Grievance Form Policy? *
To which staff member is your grievance against? *
Have you attempted to address your grievance with the above named DHHSC staff? *
Please explain in as much detail as possible the reason for your grievance? *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of DEAF AND HARD OF HEARING SERVICE CENTER INC. Report Abuse