client grievance form | NoCo

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This form is

Name/Nombre*

Email address / Dirección de correo electrónico*

Date/Fecha

A#*

Please provide a brief summary of your grievance/complaint | Proporcione un breve resume de su queja, por favor:

How can your grievance/complaint be satisfactorily addressed? | ¿Como se puede atender satisfactoriamente su queja?

Staff member who received the complaint | Miembro del personal que recibió la queja:

Follow-up meeting date(s) | Fecha(s) de la reunión de seguimiento:

Final resolution date | Resolución final:

Date | Time Reviewed:

Administrator’s Comments (Resolution)

Program’s Follow-Up Measures (include targeted dates if applicable)

Staff Member Comments

Additional Mediation Required (Yes/Explanation or No)

Resolution Form provided to staff, if applicable, by:

Staff Signature

Date Field

Administrator's Signature

Date Field