Form 95 - Complaint Form
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1
2COMPLAINT FORM
FORM 95
Date stamp
Part 1 Complainant Details
Complainant Name
Date of Incident
Address
Email
Fax
Phone
Mobile
Part 2 Nature of Complaint (additional space provided overleaf if required)
Part 3 Signature of Complainant
I hereby declare that the information provided on this form is true and correct.
Signature of Applicant
Date
Name
Part 5 OFFICE USE ONLY Action Taken
Ask complainant what course of action they are looking for:
Proposed resolution:
Ask Complainant if they are satisfied with proposed action:
Copy of Letter Attached
Date Letter Sent
Provide ‘standard’ letter of acknowledgement of the complaint:
Yes
No
If not dealing with issue personally, name of person referred for follow up referral (ensure complainant has received feedback):
Date
Copy forwarded to Chief Executive Officer for Complaints Register
Yes
No
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Parent category: Legal