Subject: Client Rights, PQI

Stakeholder Complaint Form

Form Number: 1027-24 Effective: June 27, 2007 Revision effective: February 7, 2013 Reviewed: February 6, 2013

COA: CR3, PQI Applies to: Entire organization SECTION A: IDENTIFYING INFORMATION: Date of initial complaint: ______________________

Name of person filing complaint: Contact information: (phone and address)

________________________________________________ ____________________________________________

Complainant grants permission for contact information to be shared with others involved in problem resolution process: Yes No
If yes, complete the following: Permission granted in person Permission granted by phone (Have complainant initial here: ________) Date: To whom:

Program/work group directly related to the complaint:

___________________________

Brief explanation of the complaint: (Encourage complainant to submit written description/explanation if possible;
however, this is not required. Preparation of complaint documentation should not be delayed pending receipt of written documentation.)

First Level staff person as identified by the complainant:

Is complainant willing to speak with First Level staff person?

Yes

No

If No, forward complaint to the First Level staff persons next level manager.

Name, program, and position of staff person who received and recorded the initial complaint:

Signature of recipient of complaint

(include credentials and position title)

Date

SECTION B: FIRST LEVEL INTERVENTION Date complaint received by First Level staff person: _______________________________

Action taken by Agency: (Include the position/title of the person attempting to resolve the complaint.)

Was stakeholder satisfied with action taken?

YES

NO

If resolved, date written notice sent to complainant: ___________________

(Should be within 3 business days of date complaint was initially received by the organization, unless additional information is required to resolve complaint.)

Need for further action?

YES

NO

If yes, list additional actions to be taken: (Include referral to next level manager if appropriate.)

First Level Staff Person

Signature (include credentials and position title)

Date

Next Level Manager

Signature (include credentials and position title)

Date

SECTION C: SECOND LEVEL INTERVENTION Date received by 2nd Level Responder: Action taken by Agency:

Was stakeholder satisfied with action taken?

YES

NO

If resolved, date written notice sent to complainant: ___________________

(Should be within 5 business days of date complaint was initially received by the organization, unless 1) additional information is required to resolve the complaint, or 2) program/work group manager was the initial responder to the complaint, in which case notice should be sent within 3 business days, unless additional information is needed is required.)

Need for further action?

YES

NO

If yes, list additional actions to be taken: (Include referral to next level manager if appropriate.)

2nd Level Responder

Signature (include credentials and position title)

Date

Next Level Manager

Signature (include credentials and position title)

Date

SECTION D: THIRD LEVEL INTERVENTION Date received by 3rd Level Responder: Action taken by Agency:

Was stakeholder satisfied with action taken?

YES

NO

If resolved, date written notice sent to complainant: ___________________

(Should be within 7 business days of date complaint was initially received by the organization, unless additional information is required to resolve complaint.)

Need for further action?

YES

NO

If yes, list additional actions to be taken: (Include referral to next level manager if appropriate.)

3rd Level Responder

Signature (include credentials and position title)

Date

Next Level Manager

Signature (include credentials and position title)

Date

SECTION E: FOURTH LEVEL INTERVENTION Date received by 4th Level Responder: Action taken by Agency:

Was stakeholder satisfied with action taken?

YES

NO

If resolved, date written notice sent to complainant: ___________________

(Should be within 9 business days of date complaint was initially received by the organization, unless additional information is required to resolve complaint.)

Need for further action? Explain the appeal process to the complainant. Does the complainant wish to appeal the decision?

YES

NO

YES

NO

Date notice of appeal (Form 1011-89) submitted to President/CEO: ____________________ Date client notified that complaint was referred for final appeal: 4th Level Responder
Signature (include credentials and position title)

_____________________

Date

Next Level Manager

Signature (include credentials and position title)

Date

SECTION F: FINAL APPEAL (President/CEO) Date received by President/CEO: Final Decision/Action taken by Agency: (to be completed within 10 days of receipt of notice of appeal)

Date written notice sent to complainant: ___________________ (to be sent within 2 day of final decision)

Was stakeholder satisfied with action taken? Need for further action? If yes, list additional actions to be taken:

YES YES

NO NO

President/CEO
Signature (include credentials and position title)

Date