Client/Service Recipient Grievance Survey

1.Please select one of the following options:

I am providing my name and contact information. I agree that Hope House can disclose my name and other information I provide, if necessary, in order to ensure my issues are addressed.

I wish to be confidential, meaning I am providing my name, but I request that Hope House not disclose my name outside the agency.

I wish to be anonymous, meaning I have not provided my name. I understand that by not providing my name or contact information, Hope House will be unable to contact me. I understand that in this case, Hope House may not have enough information to pursue my concern and I may not be able to find out the results of any investigation conducted.

2.Name

3.Safe Contact Phone Number

4.Safe Email Address

5.What would you like to report?

Violation of my right to privacy and confidentiality

Unethical and/or unprofessional service delivery

Unsafe, indecent, and/or unsanitary housing

Discrimination

Mistreatment from an employee or volunteer of Hope House

Other (please specify)

6.Name of the alleged violator, if known.

7.What is the problem and/or concern you want to report? Please provide a description of the facts and circumstances surrounding the reported activities, including evidence forming the basis of this report. Include specific information, including the date of the event and/or a timeline of events that led to this grievance.

8.When and how did you become aware of the problem? Please identify potential witnesses and their involvement and any corrective action taken by you, the company, or any other entity.

9.How long has the problem existed?

10.When was the most recent occurrence of this problem?

11.Is there any additional information that might be useful to us in evaluating this complaint?

12.What is your desired outcome?

Current Progress,

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