Community/parent Complaint Form

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HEAD START COMMUNITY/PARENT CONCERNS/COMPLAINT FORM
Name ____________________________________
Date ________________
Address__________________________________________________________
Phone ____________________
Work/Other Phone ______________
Head Start Child’s Legal Parent/Guardian ______ Community Member ________
Other (Please describe)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Child’s Name (if applicable)__________________________________________
Center Location: Carbondale ___ Marion ___ Murphysboro ___
Co-Location (Malone’s) ____
Attendance ___am ____ pm ____all day
Nature of complaint. Please explain and describe the incident(s) in detail and
Attach to this form. Cite times, dates, witnesses, and events.
What Corrective action would you like to see taken regarding this complaint?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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(Add pages if necessary)
____________________________________
___________________________
Signature of Complainant
Date
Center Director
Date

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