Complaint Form

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About You

Your Name (optional)

Advocate Name (if you wish to nominate one):

Your postal address: (optional)

Telephone: (optional)

E-mail: (Optional)

Question 2. Who is the complaint against?

Business/Organisation/Agency:

The person’s name (if known):

Their position (if known):

Is this complaint service related:

Yes

Employer’s name if service related:

Question 4. Where did the incident happen (please tick a box)?

employment/work

clients home

car

outing/activity

Something not listed here - please explain:

Question 5. Explain what happened and why you think the way you were treated was based on your attribute at question 3.

Question 6. Have you talked to another organisation about this? If so, write the name of the organisation and the person you dealt with there:

Question 7. Have you tried to talk to who you are complaining about or have you tried to sort out this complaint in any other way? If you did, write what happened here:

Question 8. Did these things happen within the last 6 months? (We may not be able to deal with matters that occurred more than 6 months ago). If other, please fully explain the reasons why you delayed making the complaint.

Question 9. What effect (financial or personal) did the incident have on you?

Question 10. Do you know anyone who saw the incident and is willing to help you with your complaint? If so, write their names and contact phone numbers here:

Question 11. Do you have any documents or anything else that has anything to do with your complaint? Please attach a photocopy.

Question 12. List anything else you think we may need to know here.

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