This is a template for a grievance or complaint form that a company can provide to its
consumers to receive feedback. This form states that the company will respond within
five (5) business days of receipt of the grievance. Additionally, this form requests that
grievances be limited to customer service complaints, however, it allows for suggestions
on how to improve service as well. This document is ideal for small businesses or other
entities that want to provide a forum for customer complaints.
[Instruction: Insert logo/name here.]
Grievance or Complaint Form
We welcome your feedback! Any and all grievances and/or complaints received will be
processed in a timely manner. You will receive a response from _____ [Instruction: Insert
company name.] regarding your grievance or complaint within five business days. We request
that all grievances or complaints be limited to customer service complaints; however, if you have
a suggestion on how we can improve our services, please do so on the form and it will be
Please return completed form should be returned to _______. [Instruction: Insert return
Please note this form should only be used for non-emergency grievances and complaints.
Grievances and complaints of an emergency nature should be addressed to ______. [Instruction:
Insert contact information.]
City: ________________ State: _____ Zip Code: ______
Phone Number: ________________
Email: _________________ Preferred Method of Return Contact: ___ Phone ___ Email
Date of Grievance/Complaint: _____
Matter of Grievance/Complaint: _____
Description of Grievance/Complaint: ______
Desired Method of Resolving Grievance/Complaints: _____
Thank you for your time. We appreciate your help in making our Company better!
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