Participant Complaint Form (Page 2 of 3) in pdf

Participant Complaint Form Page 2

PARTICIPANT COMPLAINT FORM

The personal information requested on this from is primarily being collected by ESSS for the purpose of

investigating and responding to a complaint. This information will be used solely by ESSS for that purpose or

directly related purposes. ESSS may disclose some of this information to relevant organizations if the nature of the

complaint involves serviced delivered/ matters dealt with by parties other than the agency. If sufficient

information is not collected on this from, Encompass Support Services may not be able to effectively address the

issue(s) raised and provide feedback to the submitter.

Name:

Date:

Address:

Daytime Contact No:

COMPLAINT DETAILS (fill out all applicable details)

Date of Incident:

Time:

Location of Incident:

Who/What is the Subject of Your Complaint:

Summary of Complaint/Issue:

(use the back of this form if necessary)

Preferred Outcome /Suggested Solution:

(use the back of this form if necessary)

Signature:

Date:

Participant Complaint Form Page 2