COMPLAINT FORM – CLIENT/STAKEHOLDER

COMPLAINT FORM – CLIENT/STAKEHOLDER

This form is to assist you when making a complaint to Ravenshoe Community Centre Inc. 

Any person wishing to make a complaint may speak with the relevant RCC Program Coordinator, Human Resource Officer, Management Group member or staff member of choice and/or choose to complete this form.

All information is strictly confidential.

We encourage you to make your complaint in writing. Please allow some time (7-10 days) for a response.

Personal details

Please provide the contact details you would like RCC to use.

Name:  Mr/Mrs/Miss/Ms  ______________________________________________________

Postal Address:  ______________________________________________  Postcode:  _____

Email: _____________________________________________________________________

Phone No:  _______________________       Mobile:  _______________________________

Have you lodged a complaint with our Organisation before?

Yes              The matter was resolved.    The matter was not resolved    No        

Comments:      _______________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Is there someone else (legal representative/advocate or support person) that you would like to be involved in resolvingthis complaint?

Yes                No       

Name of legal representative/advocate/support person _______________________________

Postal Address:  _____________________________________________________________

Phone:  ______________________   E-Mail:  _____________________________________

Details of the complaint

 


Is the complaint related to:

 Employee of the organisation          

 Volunteer of the organisation           

 Service delivery                                

 Facilities                                           

 Specific incident                               

 External person/agency                    

 Other                                                

What happened?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Where did it happen?

______________________________________________________________________________________________________________________________________________________

When did it happen? (Include date if possible)

___________________________________________________________________________

Who was involved? (List all persons involved and witnesses)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any other relevant details:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you discussed the matter with the person/s involved?

Yes               No    

If yes, what was the outcome, if any? Please attach a copy (not the original) of your complaint to the respondent and any letter of reply you have received.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If no, is there any reason/s that you cannot do so? Do you need help to do this, e.g. for safety reasons, cultural reasons?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How would you like to see your complaint resolved?  What action would you like the Organisation to take to resolve your complaint?

______________________________________________________________________________________________________________________________________________________

___________________________________________________________________________

Additional information/supporting documentation

Please attach copies (not the original) of any documents that may help us to resolve the complaint, e.g. if you have letters, emails or faxes or records of conversations you have had with the person/s associated with the complaint.

To help us resolve this matter as fast as we can, please ensure your contact details are kept up to date. If details change, let the Organisation know as soon as you can. 

Please sign and date this form.

Signature:  _____________________________________    Date:  _____________________