INDIVIDUAL GRIEVANCE FORM
Name of Individual Receiving Services:
*
First Name
Last Name
Service location pertaining to grievance:
*
Park West ICF
SCL
Johnstown ICF
Open Door
CAC
UCO
Transportation
Date of grievance:
*
-
Month
-
Day
Year
Date
Explanation of grievance (per individual/family/guardian report)
*
Name of staff that grievance is being filed on (if applicable)
First Name
Last Name
Other Name of staff that grievance is being filed on (if applicable)
First Name
Last Name
Name of person assisting with grievance submission:
*
First Name
Last Name
Email of person assisting with grievance submission:
*
example@example.com
Please detail what information was gathered from staff:
Please detail what information was gathered from individual/family/guardian:
Follow-up actions taken:
Name of Social Worker completing follow-up:
First Name
Last Name
Email of Social Worker completing follow-up:
example@example.com
Submit
Should be Empty: