Grievance Report Form for Members, Program Participants or Parents/Guardians to Report Concerns
At the Greater Joliet Area YMCA, we are committed to fostering a safe and respectful environment for all individuals, especially in our efforts to prevent misconduct. This Grievance Form is intended for reporting serious concerns, such as violations of our safety policies, boundary breaches, or any behavior that raises suspicion or discomfort, particularly those that may indicate a risk to the well-being of others. After submitting this form, you can expect to be contacted by a member of our staff team within two business days to discuss your concerns and next steps.
Individual filing concern:
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Name of individual or YMCA location this concern is about:
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Role (i.e. member, program participant or parent/guardian):
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Date of occurrence:
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Month
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Day
Year
Date
Time of occurrence:
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Other individuals involved/witness to complaint:
Type of Concern (select all that apply):
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Inappropriate behavior by employees/volunteers
Inappropriate behavior by consumers
Retaliation
Whistleblower complaints
Other reported matters
Describe the situation: what happened, where it happened, when it happened, who was involved, who was present, who was notified? If suspected abuse, was it reported to the state?
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Has this situation ever occurred previously (please explain):
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Describe the remedy you seek. Please list all remedies sought due to reporting this concern. What corrective action are you seeking to resolve this issue?
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Submitted by:
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Phone Number:
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Email:
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example@example.com
Signature:
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Date:
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Month
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Day
Year
Date
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Submit
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