PARTICIPANT COMPLAINT FORM
Name: Mr / Mrs / Miss / Ms
First Name
Last Name
Postal Address:
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City
State / Province
Postal / Zip Code
Postcode:
Street Address
Street Address Line 2
City
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Email:
Phone No:
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Area Code
Phone Number
Mobile:
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Area Code
Phone Number
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Details:
Career:
Advocate:
Guardian:
Translator:
Have you lodged a complaint with our organization before?
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No
If yes, was the matter resolved?
Comments:
Is there someone else (legal representative or support person) that you would like involved in making this complaint?
Please Select
Yes
No
If yes, what is the name of the legal representative/support person?
Name:
First Name
Last Name
Postal Address:
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
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Area Code
Phone Number
Email:
Details of the complaint
Is the complaint related to:
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Employee of the organisation
Volunteer of the organisation
Service Delivery
Facilities
Specific Incident
Details:
What happened?
Where did it happen?
When did it happen? (Include date if possible)
Who was involved? (List all persons involved and witnesses)
Did someone witness the incident? Would they be willing to be contacted regarding yourcomplaint? If so, provide the name and contact details. (Inform the witness that they may becontacted by the organization to discuss the matter)
Any other relevant details:
Have you discussed the matter with the person/s involved?
Please Select
Yes
No
If yes, what was the outcome, if any? Please attach a copy (not the original) of your complaint to the respondent and any letter of reply you have received.
If not, is there any reason/s that you cannot do so? Do you need help to do this, e.g. for safety reasons, or cultural reasons?
How would you like to see your complaint resolved? What action would you like the organization to take to resolve your complaint?
Additional Information/Supporting Documentation
Please attach copies (not the original) of any documents that may help us to handle the complaint, e.g. if you have letters, emails or faxes or records of conversations you have hadwith the person/s associated with the complaint.
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To help us resolve this matter as fast as we can, please ensure your contact details are keptup to date. If details change, let the organisation know as soon as you can.
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Date
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Complaint Investigation
Complaint Number:
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Area Code
Phone Number
Relevant Department:
To be Investigated By:
Investigation Deadline:
Investigator Remarks:
Resolved:
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No
Investigator Signature:
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Resolution Approved by:
Resolution Date:
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