ACHIEVING BETTER COPING SKILLS LLC
GRIEVANCE FORM
Achi
eving Better Coping Skills LLC maintains a log of grievances filed. All grievances are for using ABC Skills LLC Company Leaders & affiliated Department of Child Safety Leaders.
Youth name filing grievance:
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First Name
Last Name
Facility location name
*
Please Select
ASHER HOUSE
SHOULDER'S HOUSE
Date grievance filed
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Grievance Incident?
Hour Minutes
AM
PM
AM/PM Option
Grievance against
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Another Housemate
Staff Member
Director
Administration
Other
Statement of Grievance. What happened? Include all relevant information including: name(s) involved, witness(es), date of occurrence, address of occurrence, and time(s) of occurrence. (Please be detailed)
*
How can this be resolved fairly and quickly? How can this be prevented in the future?
*
Youth Signature
*
Resolution of Grievance (To be Filled by Director and Admin Only)
Date Resolved
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Director/Admin
First Name
Last Name
Signature of Director/Admin.
Submit
Should be Empty: