Caring with a Purpose Home Care – Client / Family / Employee Complaint & Grievance Form

Caring with a Purpose Home Care – Client / Family / Employee Complaint & Grievance Form

Please use this form to report concerns or grievances regarding services, staff, or other issues related to Caring with a Purpose Home Care.
Caring with a Purpose Home Care Client / Family / Employee Complaint & Grievance Form
Section 1: Complainant Information
Name*

First NameLast Name
ClientFamily/Representative of clientEmployeeOther
Other (please specify)*
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Section 2: Client Information (if different from above)
Client name

First NameLast Name
Service address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Section 3: Incident Information
Date(s) of incident
Approximate time(s)
HomeCommunityOther
Location (please specify)*
Name(s) of staff or person(s) involved (if known)
Section 4: Description of Complaint or Grievance
Please describe what happened. Include specific dates, times, who was involved, and what was said or done. Use additional pages if needed.*
Section 5: Impact of the Issue
How did this situation affect you, the client, or services (for example: safety, comfort, dignity, schedule, finances, work environment, etc.)?
Section 6: Previous Steps Taken (if any)
Have you talked with anyone at Caring with a Purpose Home Care about this issue before? If yes, who and when? What was the response?
Section 7: Requested Resolution
What would you like Caring with a Purpose Home Care to do to resolve this concern? (For example: investigate the incident, change staff, adjust schedule, provide more training, correct records, respond in writing, etc.)
Section 8: Supporting Documents
Upload supporting documents (notes, texts, emails, photos, care logs, etc.)

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Please list any documents you are attaching (notes, texts, emails, photos, care logs)
Section 9: Confidentiality and Retaliation
Caring with a Purpose Home Care does not tolerate retaliation against any person who submits a concern in good faith.
If you are worried about retaliation, please explain:
Section 10: Signature
I affirm that the information I have provided is true and complete to the best of my knowledge.
Complainant signature*
Date*

MonthDayYear
Date
Should be Empty:

Caring with a Purpose Home Care – Client / Family / Employee Complaint & Grievance Form

Caring with a Purpose Home Care Client / Family / Employee Complaint & Grievance Form

Section 1: Complainant Information

Section 2: Client Information (if different from above)

Section 3: Incident Information

Section 4: Description of Complaint or Grievance

Section 5: Impact of the Issue

Section 6: Previous Steps Taken (if any)

Section 7: Requested Resolution

Section 8: Supporting Documents

Section 9: Confidentiality and Retaliation

Section 10: Signature