[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
addressed accordingly.
Please return completed form should be returned to _______. [Instruction: Insert return
instructions.]
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.]
Name: _____
Address: _____ 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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