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Complaint Record Form
This form is to be filled out by a representative when a complaint is to be submitted.
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Date complaint received:
MM
/
DD
/
YYYY
Name of person receiving complaint:
Your answer
Position:
Your answer
Does the person making the complaint wish to remain anonymous?
Yes
No
Clear selection
If no, name of person making complaint:
Your answer
Category of person making complaint: (/Family member/Friend/Advocate/Guardian/Manager/Other provider/Staff member/Other) ___________________________________________
Participant
Family member
Friend
Advocate
Guardian
Manager
Other provider
Staff member
Other
Clear selection
Preferred method of contact:
Email
Phone
Letter
Clear selection
Phone
Your answer
Email
Your answer
Postal Address
Your answer
Name of participant complaint is regarding:
Your answer
Is the participant an existing client?
Yes
No
Clear selection
Can we speak to the participant about this complaint?
Yes
No
Clear selection
Description of complaint:
Your answer
What is considered appropriate resolution by the person making the complaint?
Your answer
Current status of complaint:
Investigating
Action proposed
Resolved
Unresolved
Clear selection
What actions have been proposed? Or if resolved, how was it resolved?
Your answer
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