WWC Service Grievance Form

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Email *

Name of person completing this form

Date of birth

YYYY

Phone Number

Are you currently receiving services from WWC?

Yes

Clear selection

Date of incident or concern

YYYY

Location of incident or concern

Telehealth

In person at Milwaukie, OR office

Email or phone communication

Clear selection

Name of individuals or staff involved (if known)

Please describe your grievance in detail (what happened, when, where, etc.)

What outcome or resolution are you seeking?

Would you like someone to follow up with you about this grievance?

Yes

Clear selection

How would you like to be contacted?

Phone

I am submitting this anonymously (Anonymous submissions will be reviewed by no follow up will be provided)

Option 4

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Clients have the right to submit a grievance to OHA directly using the link below. When grievances can be addressed and rectified internally with WWC, the organization will not file a grievance with OHA directly. Clients are encouraged to work with WWC directly whenever possible to come to a satisfactory and timely conclusion of concerns.

https://www.oregon.gov/oha/HSD/AMH-LC/Pages/Complaints.aspx

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