Records of Complaints

COMPLAINT BY WHOM(Required)

DATE

MM slash DD slash YYYY

COMPLAIN IS

Anonymous

Employee

Former Employee

Client

Client's Family/Friend

Outside Agency

Other

COMPLAINT MADE

In writing

Personally

By Telephone

COMPLAINT WAS MADE TO

NATURE OF COMPLAINT

WHO INVESTIGATED THE COMPLAINT?

HOW THE COMPLAINT WAS INVESTIGATED?

FINDINGS OF INVESTIGATION

IF A COMPLAINT JUSTIFIED, STEPS TAKE TO CORRECT THE CONDITIONS

INFORMATION SENT TO

STAFF SIGNATURE(Required)

MANAGER'S SIGNATURE (OFFICE USE ONLY)

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