COMPLIANT & GRIEVANCE FORM

Name *

Phone number *

Email Address *

Relationship to Youth, Adolescent or Individual *

DETAILS OF OCCURENCE LEADING TO GRIEVANCE

Date of Occurence * +

Time of Occurrence *

Location of the Occurence *

Witnesses (if applicable) *

Account of the Occurence or Issue (Provide a detailed account of the occurrence. Include the names of any additional persons involved.) *

Violations (Provide a list of any rights or privileges you believe have been violated in the occurence described.) *

Basis for Complaint *

I affirm that all of the information is correct to the best of my knowledge.

Date: * +

Medicaid Fraud, Waste & Abuse	Discrimination
Harassment	Bullying
Retaliation	Youth, Adolescent or Individual's Rights Violations or Infringement
Inappropriate Workplace Behaviors	Other Other