Grievance Log Template
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1Acknowledgement Letter Provided?
Month: _________
Yes No Date: __________
Year: ___
_____
Outcome Letter Provided?
Yes No Date: __________
Grievance Log
Date Grievance Filed: ____________
Grievance entered by (Staff person): _ ________________________________________________
Yes
No FA/CM Initials: _______
Reported to Facility Administrator/Clinic Manager?
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):
Resolution:
Was the grievant provided a verbal explanation of the above resolution?
Yes No
Date: ___________
Was the Grievance escalated? No
If so to whom: _________________________________________________________________________
*Please attach any documentation regarding the escalation of the grievance.
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Parent category: Business