TES Grievance Form

TES Grievance Form

To request assistance in resolving a concern with TES, please complete this form.
Client Name *

First NameLast Name
Complainant Information
Complainant Name*

First NameLast Name
Relationship to client:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Facility Associated with Grievance*

CA: AlhambraCA: Los AngelesCA: LynwoodCA: SacramentoCA: San DiegoCA: South Pasadena (HQ)MI: TroyOH: ColumbusOH: FairlawnOnline: TES ConnectOther
Please check one*

I have approached the facility with my grievance and am not satisfied with the outcome.I have not approached the facility with my grievance.
I have not approached the facility with my grievance because*
Grievance Description

Please describe the following below:
1. Your concern with as much detail as possible.
2. List dates and approximate times when the incident occurred.
3. If necessary, attach other documentation
Description of Grievance: *
Necessary Documentation

Cancelof
Consent to Disclose Identity

Total Education Solutions (TES) will not reveal your name to any facility or employee named in your grievance without your consent. If you do not give permission to TES to use your name, we will handle your concern as an anonymous grievance. An anonymous grievance may be more difficult to investigate, which may prevent your concerns from being fully addressed. It is important for you to know that it is unlawful for a facility or its staff to retaliate against a patient or another individual for filing a grievance. If at any time you feel that you are being discriminated against or treated unfairly, please contact TES immediately.
Please check one*

I consent to allow TES to disclose my identity to the appropriate individuals in the course of processing this grievance.I choose to remain anonymous. I understand that remaining anonymous may result in the inability to fully process my grievance. If this occurs, the company will notify me.
Complainant Signature*

Clear
It is important for you to know that it is unlawful for a facility or its staff to retaliate against a patient or another individual for filing a grievance. If at any time you feel that you are being discriminated against or treated unfairly, please contact TES
immediately.
For Office Team: Timeline Reminder
Telephone: A return call is expected within three (3) business days.
In-Person: An appointment to discuss the grievance will be scheduled within five (5) business days if necessary.
In Writing: A follow-up phone call is expected within three (3) business days.
Please verify that you are human*
Should be Empty:

TES Grievance Form

Complainant Information