Client Grievance Form

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* 1. Name

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* 2. What is your preferred email address?

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* 3. What is your preferred phone number?

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* 4. Date and Time of Grievance

Date / Time of Event

Date

Time

AM/PM

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* 5. Location of Event

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* 6. Please describe your complaint in factual details (who, what, when, where):

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* 7. Please describe why you believe the action was wrongful, illegal, or unlawful:

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* 8. Please describe the resolution you are seeking for this complaint:

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* 9. If you choose, please provide the names of any individuals who may have been witness to the event or events that led to the filing of this grievance.

Thank you for taking the time to fill out a grievance report. NBCC-BCC takes grievances very seriously and will respond promptly. Please refer to your program handbook/ask your counselor for an explanation of the grievance process.