Grievance/ Complaint Form
Grievance/Complaint Form
Please complete the form to the best of your ability. If you would like to remain anonymous, please do not enter any identifying information.
1.
Name of Persona Filing Grievance/Complaint:
2.
Date:
3.
Name of Individual:
4.
Individual DOB:
5.
Relationship to Individual:
6.
Mailing Address:
7.
Describe your complaint in detail including the following as applicable: (a written statement may be attached or used instead of the form):
1. A statement of facts upon which the alleged rights violation is based.
2. The party allegedly responsible.
3. A proposed solution to the issue.
8.
Complaint: