Complaint Report (CO)
Today's Date
*
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Month
-
Day
Year
Date
Name of Consumer
*
First Name
Last Name
Bridges of Colorado Contract Manager
*
LaTasha Stephenson
Amber Barger
Date Complaint / Issue Occurred
*
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Month
-
Day
Year
Date
Complaint (Describe in Detail the Complaint / Issue being reported)
Reporting Party (Name of person completing this form)
*
First Name
Last Name
Signature of Reporting Party
Submit
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(NEXT) Click here to Enter Follow Up Information
TO BE COMPLETED BY SUPERVISOR
COMPLAINT FOLLOW UP
Was complaint/issue resolved?
Yes
No
Date of Resolution
*
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Month
-
Day
Year
Date
Resolution: (Please list all details regarding complaint resolution)
*
Person Responsible for Completing Follow Up:
First Name
Last Name
Follow Up Actions:
Date Follow Up Completed
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Month
-
Day
Year
Date
Signature of Person Completing Follow up
Submit
Should be Empty: