Individual Feedback Form

Individual Feedback Form

(See full policy below)
Individual's Name

First NameLast Name
Date

MonthDayYear
Date of Occurrence
Filer's Name

First NameLast Name
Filer's Relationship to Individual
Feedback Type
Please describe your feedback, concern, complaint, suggestion, compliment, or recommendation for improvement.

Include as much detail as possible, including the date(s), location(s), names of individuals involved (if applicable), witnesses (if any), and any supporting information or documentation you would like to provide.
- Unity of Indiana
  Individual Feedback, Complaints, and Resolution Policy
  
  Purpose
  Unity of Indiana is committed to promoting a culture of continuous quality improvement by encouraging Individuals, legal representatives, family members, and other authorized persons to provide feedback regarding the services they receive. Feedback may include compliments, suggestions, concerns, complaints, recommendations for improvement, or reports of potential rights violations.
  
  Unity of Indiana maintains an open feedback channel that is available to Individuals at all times and is committed to ensuring all Individuals have an equal opportunity to provide feedback without fear of retaliation.
  
  Policy
  Unity of Indiana shall maintain at least one open feedback channel that is available to Individuals at all times.
  
  Individuals shall be informed of available feedback channels:
  - At the initiation of services;
  - At least annually thereafter;
  - Whenever requested by the Individual or their legal representative.
  Documentation that the Individual has been informed of available feedback channels shall be maintained in the individual's record.
  
  Available Feedback Channels
  Individuals may provide feedback at any time through any of the following methods:
  - Speaking directly with their assigned Case Manager.
  - Contacting the Chief Operations Officer.
  - Contacting the Compliance and Quality Assurance Officer.
  - Calling Unity of Indiana's main office during normal business hours.
  - Leaving a voicemail after business hours, which is available twenty-four (24) hours per day, seven (7) days per week.
  - Sending an email to the agency.
  - Mailing written correspondence to Unity of Indiana.
  - Completing any agency-provided feedback or complaint form.
  Feedback may be submitted anonymously whenever practical. All feedback received shall be reviewed and handled according to this policy.
  
  Public Availability
  This policy shall remain publicly available at all times.
  
  Unity of Indiana will make this policy available by:
  - Posting the policy on the Unity of Indiana website.
  - Providing printed copies upon request at no cost.
  - Maintaining copies at all Unity of Indiana office locations.
  - Including information regarding available feedback channels within agency informational materials provided to Individuals.
  Language Access and Accommodations
  Unity of Indiana is committed to ensuring every Individual has meaningful access to provide feedback regardless of language, disability, or communication needs.
  
  At no cost to the Individual, Unity of Indiana shall provide appropriate supports including, but not limited to:
  - Qualified interpreter services.
  - Written translation services.
  - Assistance from qualified language interpretation vendors.
  - Large-print or alternative-format documents.
  - Assistance completing feedback or complaint forms.
  - Communication supports for Individuals with hearing, vision, speech, intellectual, developmental, or cognitive disabilities.
  - Other reasonable accommodations necessary to ensure meaningful access to the feedback process.
  No Individual shall be denied the opportunity to provide feedback because of communication barriers or disability.
  
  Complaint Resolution Procedure
  Unity of Indiana Individuals are afforded certain rights and protections guaranteed by law and by Unity of Indiana policies. If an Individual believes those rights have been violated, they are encouraged to report the concern immediately.
  
  Individuals may file a complaint at any time by contacting their Case Manager, the Chief Operations Officer, or the Compliance and Quality Assurance Officer.
  
  If the complaint involves the Case Manager or Chief Operations Officer, the Individual may contact the Compliance and Quality Assurance Officer directly, who functions independently of Operations and reports directly to the President/Chief Executive Officer.
  
  Individuals may choose to have a guardian, family member, advocate, or other trusted person assist them with submitting a complaint.
  
  When appropriate, Individuals may be asked to complete a written complaint form to assist with documenting the concern; however, submission of a written form is not required for Unity of Indiana to begin reviewing a complaint.
  
  Investigation Process
  Upon receipt of a complaint, Unity of Indiana shall promptly begin an investigation.
  
  The investigation may include:
  - Interviewing the Individual.
  - Interviewing employees or other persons with relevant knowledge.
  - Reviewing records and supporting documentation.
  - Reviewing applicable policies, procedures, and regulations.
  Whenever possible, investigations will be completed within seven (7) calendar days.
  
  Health, Safety, and Welfare Concerns
  If a complaint involves an immediate threat to an Individual's health, safety, or welfare, Unity of Indiana shall immediately implement protective measures, which may include removal of involved personnel from direct contact pending the outcome of the investigation.
  
  Required Incident Reports shall be submitted in accordance with applicable Indiana Administrative Code, Indiana Code, Bureau of Disabilities Services requirements, and other applicable regulations.
  
  Law enforcement, Adult Protective Services, Child Protective Services, or other regulatory agencies shall be contacted whenever required.
  
  Accessibility Concerns
  Complaints involving accessibility or disability accommodations shall be investigated using this policy and applicable requirements under the Americans with Disabilities Act (ADA). Individuals shall also be provided information regarding their rights to pursue complaints through appropriate external agencies when applicable.
  
  Resolution and Follow-Up
  Upon completion of the investigation, Unity of Indiana shall communicate the findings and any appropriate resolution to the Individual or legal representative.
  
  Whenever appropriate, a face-to-face or other mutually agreed upon follow-up meeting shall be conducted to discuss the outcome and answer questions.
  
  Appeal Process
  If an Individual disagrees with the investigation findings or resolution, they may request further review by the President/Chief Executive Officer.
  
  If the Individual remains dissatisfied after the internal review process, they shall be informed of their right to contact the Indiana Bureau of Disabilities Services (BDS) or other appropriate oversight agencies.
  
  Non-Retaliation
  Unity of Indiana prohibits retaliation against any Individual, guardian, family member, representative, employee, or other person who submits feedback or files a complaint in good faith.
  
  No Individual's services or supports shall be adversely affected because they exercised their right to provide feedback or submit a complaint.
  
  Quality Improvement
  The Compliance and Quality Assurance Officer shall review feedback, concerns, and complaints to identify trends, opportunities for improvement, staff education needs, corrective actions, and systemic quality improvement initiatives.
  
  Feedback shall be incorporated into Unity of Indiana's Quality Assurance and Performance Improvement Program to improve the quality of services provided to Individuals.
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