FEEDBACK AND COMPLAINT FORM Your voice matters. We are committed to listening and improving our services. This form is secure. I. Who is submitting?Submission Type(Required) I am providing Feedback I am making a formal Complaint I am giving a Compliment Do you wish to remain Anonymous?(Required) Yes, please keep my identity anonymous. Your Name First Last Relationship to Participant(Required)I am the ParticipantFamily MemberAdvocate/Support CoordinatorOtherEmail(Required) Phone(Required)II. What Happened?Date of Incident DD slash MM slash YYYY Who is this regarding?Name of staff member or service involvedDetails of Feedback/Complaint (Please describe the event or feedback in detail.)Tell us what happened, where it happened, and who was involved...III. ResolutionWhat would you like to see happen to resolve this?e.g., An apology, a change in policy, staff retraining, etc.IV. Consent & SubmissionConsent(Required) I consent to HHH Solutions using this information to investigate and resolve my complaint.
