Initial Complaint Form

Initial Complaint Form

Complete this form to file a complaint related to the company.
Type of Complaint:*
Please note: The Company may still determine in its discretion that a formal complaint and investigation is required.
I am completing this report on behalf of:*

ClientCaregiverMyselfOther
Do you wish to remain anonymous for this report?*

YesNo
Name of person filing complaint: (This should be the name of the person who called the office to file a complaint NOT the name of the office completing this form)*
Select the name of the company this report is regarding:*
Select the general topic the complaint falls under:
Enter Complaint Topic:*
Who is the complaint about and what is their relationship to the victim?*
Was management aware of this problem prior to your filing this complaint?*

YesNoI do not knowDo not wish to disclose
If yes, who has been made aware? Please elaborate.
Any persons mentioned here will be restricted from access to this reported information.
Please provide all details regarding the incident, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation:*
Where did this incident or violation occur?*
We recognize that this incident may not have occurred in a particular location. Please indicate if the incident was observed in some documentation or business transactions.
Please provide the specific or approximate date and time this incident occurred?*
How long do you think this problem has been going on?*
Please identify the name and title of any persons who have attempted to conceal this problem and the steps they took to conceal it. Identify if you believe that management was involved. (If not applicable write N/A):*
N/AExamples: Ignored it, changed documents, said it was not a problem, said they would look into it
Upload any document or file you have that supports your report:

Cancelof
Name of Person Completing this Form*
Title of Person Completing this Form*
Signature of person completing this Form*

Clear
Date*

MonthDayYear
Please complete the following:*
Please identify the person(s) engaged in this behavior:*
Please provide all details regarding the alleged violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation:*
Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so. It may be important to know if you are the only person aware of this situation.
How did you become aware of this violation?*
If other, how?
Do you want to file this as a formal complaint?*

YesNo
Should be Empty: