Service Grievance FormPlease complete this form in its entirety. Once submitted you will receive a response within 7 business days. PART 1: BASIC INFORMATION Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Country (###) ### #### Email * Preferred Contact Method * Please choose your preferred method of contact. Email Phone PART 2: DETAILS ABOUT THE COMPLAINT Name of Resource * The name of the resource in which the affected person served currently resides. Are you initiating this complaint on your own behalf, or on the behalf of someone else? * On my own behalf On behalf of someone else If this complaint is on behalf of someone else, please provide his/her full name. Please select the type(s) of concern(s) you would like addressed. * Quality of Services Received Conduct of IDM Employees IDM Policy or Practice Respect for the Rights of an Individual Privacy/Handling of Personal Information Other If ‘other’ please describe. Have you tried to discuss this with the Resource Manager at the specific resource? * Yes No If yes, what options or support were offered to you? To assist us in resolving the situation as quickly as possible, please utilize this last comment box with any other information you wish to disclose. Thank you for your feedback. You will hear from the Quality Assurance Coordinator within 7 working days of submitting this form.
