Grievance Log - The Renal Network
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1
2Acknowledgement Letter Provided?
Month: _______________
Yes
No
Date: __________
Year: _________________
Outcome Letter Provided?
Grievance Log
Yes
No
Date: __________
Date Grievance Filed: ________________
Facility Name:______________________________________ Facility Provider Number:__________________________
Grievance entered by (Staff person): ___________________________________________________________________
Reported to Facility Administrator/Clinic Manager?
Yes
No
FA/CM Initials: _______
Name of Grievant: _____________________________________________________________________
Description of Grievance:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Actions/Steps Taken:
Date: ___________
Actions/Steps completed by (Staff person): ______________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date: ___________
Actions/Steps completed by (Staff person): ______________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date: ___________
Actions/Steps completed by (Staff person): ______________________________
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Parent category: Business