COMPLAINT FORM

 

Date:______________________ Time:_____________________________

 

RECEIVED IN BY:__________________________________________________________________________________

 

REPORTING PARTY:_______________________________________________________________________________

 

ADDRESS/ PHONE #:_______________________________________________________________________________

 

LOCATION:______________________________________________________________________________________

 

NATURE OF COMPLAINT: _________________________________________________________________

 

--_____________________________________________________________________________________

 

--_____________________________________________________________________________________

 

_____________________________________________________________________________________________________

 

 

DEPARTMENT USE ONLY:

 

ROUTED FOR ACTION TO:__________________ DATE:_____________________ TIME:_________________

 

DESCRIPTION OF THE ACTION TAKEN:________________________________________________________

 

___________________________________________________________________________________________