Participant Complaint Form Page 3
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3PARTICIPANT COMPLAINT FORM
Follow Up Form (Employee Use Only)
Complaint made: By Phone _______
In Person _______
In Writing _______
Received by: _____________________________
Date: _________________________
Routed to: _______________________________
Date: _________________________
Acknowledgement: By Phone _______
In Person _______
In Writing _______
Date of Acknowledgement: ______________________________
Action taken: (up to and including final response to complainant)
Was a Final Response provided to the complainant? Yes ___________ No_____________
Date Complainant was contacted: __________________________
Additional Comments:
Close date: _______________________
Employee Signature: ______________________
Program Manager or Executive Director Signature __________________________________
Participant Complaint Form file location: I:General StaffHR FormsParticipant Complaints
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