Step Ahead Enterprises

Step Ahead Enterprises

Grievance Form
The licensee maintains a log of grievances filed against licensee. May be kept in centralized log or at each facility.
Facility Name
Grievance Youth Name

First NameLast Name
Date of Incident

MonthDayYear
Time of Incident
Location of Incident
Statement of Grievance
Write down your grievance in detail. Include all relevant information including names of individuals involved, witnesses, date of occurrence, address of occurrence, and time of occurrence.
Resolution
How can this be resolved fairly and quickly? How can this be prevented in the future?
Youth Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Administration Notified
If YES, Name of Administrator
Step Ahead Staff Name

First NameLast Name
Should be Empty: