PHR Participant Public Grievance Form

It is Painted Horse Recovery's goal to maintain a trauma-informed, inclusive, and anti-racist workplace environment. Painted Horse Recovery encourages participants and community partners to express any concerns about service-related issues, including disrespectful communication, discrimination, unresolved conflict, and any other concerns related to service delivery.

This grievance form is for individuals to complete if they would like to file a formal grievance. This form will be submitted to Human Resources.

If you would prefer to complete a paper copy of this form, you may request a printed copy from any member of staff.

Please select which department this grievance is in relation to:*

Date*

Date

What location is this grievance in reference to?*

Multnomah (Portland Metro Area)Marion County (Salem)Douglas County (Roseburg)Jackson County (Medford)

Describe in detail the nature of your grievance*

If applicable, did you talk to the staff person directly regarding concern?

YesNo

Name of the person reported the grievance to:

Please describe your desired resolution or steps that should be taken to prevent future events like this:

Please describe the steps you took, if any, to resolve this grievance with anyone prior to completing this form:

Would you like a member of Painted Horse Recovery's leadership team to reach out to you?*

YesNo