Provider Complaint Form

Provider Complaint Form
The Idaho Council on Domestic Violence and Victim Assistance (ICDVVA) has an established procedure for complaints filed against service providers funded by ICDVVA. Please review the Complaint Policy before filing a complaint. The complaint policy is included in the ICDVVA Grant Administration Policy and Procedures document (pp. 20-27) available on the ICDVVA website.
Complainant Information

Please provide name and contact information for person filing the complaint. Contact information will be kept confidential, and is for use by ICDVVA staff members only.
Complaint Made By:*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address (not required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please check the box below if you would like your name withheld from the agency during our investigation.

I would like to remain anonymous
Subject of Complaint

Please provide the name of the agency that is the subject of the complaint, including agency contact information, and a brief description of the nature of the complaint.
Agency Name:*
Complaint is Against:

First NameLast Name
Details: Please include a brief summary of your complaint, including as much detail as you can so that we can investigate (for example, the basis for the complaint, dates, times, names of witnesses with their contact information, if applicable, and other relevant information.) If there are documents that relate to this complaint, they may be submitted in the field below or by uploading documentation.*

0/500
Attach any supporting documentation below:

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By signing and submitting you are acknowledging that this complaint is true, accurate, and complete to the best of your knowledge. You also acknowledge that per policy, ICDVVA will contact the provider about your complaint and initiate an investigation*

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Date:
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Provider Complaint Form

Complainant Information

Subject of Complaint