Form Rfa 9099 - Complaint Investigation Report
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3State of California – Health and Human Services Agency
California Department of Social Services
COMPLAINT INVESTIGATION REPORT
County:
FOR COUNTY USE ONLY
Address/Contact Information:
Amended: ____________________
(Date of Original Report)
Complaint ID Number:
Purpose of Form: This is an official report of an investigation of a complaint received in our office on
____________________________________ and conducted by ___________________________________.
(Print Name and Title)
(Date received in office)
It is the intent of the RFA worker to conduct all interactions and communications with the Resource Family with
courtesy and respect and to be minimally disruptive to the Resource Family and the children in their care while
also ensuring that the home is a safe and nurturing placement.
RF Name:
RF ID:
Capacity:
Census:
Address (Street, City, State, Zip Code):
Telephone Number:
Met with _________________________________ on ____________ from ____________ to ____________
(Print Name )
(Start Time)
(End Time)
(Date)
Announced
Unannounced
(Confidential/Public Depending on Type of Information)
Distribution: Original: County
Copy: Resource Family
RFA 9099 (10/17) (Mandatory)
Page 1 of ____
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