LEICHHARDT HOUSE: COMPLAINT FORM
See, Leichhardt House: Code of Conduct, Section 11
Complainant (the one making a complaint) name:
*
Given name(s)
Family name
Complainant is a:
Parent
Carer
Boarder
Volunteer
Visitor
Other
Parent/Carer of (if applicable):
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Alternate Phone Contact
Please enter a valid phone number.
Email
*
example@example.com
Complainee (the subject of a complaint) name:
*
Given name(s)
Family name
Complainee is a:
*
Hostel staff member
CSAA Committee member
Parent/Carer
Boarder
Volunteer
Other
Details of incident
Date & Time the incident happened
*
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
The incident happened at:
*
Leichhardt House
Chinchilla SHS
Chinchilla CC
Social Media
Third Person
Other Address
Other
Specify location and address of incident (If applicable)
*
Street Address
Town/Suburb
State
Postcode
Postal / Zip Code
Please provide details of the complaint (Provide as much detail as possible)
*
Upload any supporting documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Details of additional incident (if applicable)
Date & Time the incident happened
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
The incident happened at:
Leichhardt House
Chinchilla SHS
Chinchilla CC
Social Media
Third Person
Other Address
Other
Specify location and address of incident (If applicable)
Street Address
Town/Suburb
State
Postcode
Postal / Zip Code
Please provide details of the complaint (Provide as much detail as possible)
Upload any supporting documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Details of additional incident (if applicable)
Date & Time the incident happened
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
The incident happened at:
Leichhardt House
Chinchilla SHS
Chinchilla CC
Social Media
Third Person
Other Address
Other
Specify location and address of incident (If applicable)
Street Address
Town/Suburb
State
Postcode
Postal / Zip Code
Please provide details of the complaint (Provide as much detail as possible)
Upload any supporting documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Have you previously tried to resolve the concerns detailed above?
*
NO
YES
If YES, When?
*
/
Day
/
Month
Year
Date
Who dealt with the matter?
*
First Name
Last Name
Role (Hostel Staff or CSAA Committee member
What was the outcome?
*
In making this complaint today, What outcome are you hoping for?
*
Submission of Complaint
I/We understand that supplying false or incorrect information on this form may lead to the reversal of a decision/alter the outcome of the complaint. I/We believe that the information I/We have supplied on this form is true and correct in every particular, to the best of my knowledge.
Complainant Name
*
First Name
Last Name
Complainant Signature
*
Date & Time
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: