Complaint Log 10-09

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					                                                                                WIC CLINIC COMPLAINT LOG
Vendor or Partcipant Name                                                                                                                                                                                                                                                                                   Revised: October 1, 2009




                                                                                                                                                                                                                                      Particoant Violations Form Documented
                                                                                                                                                                 Vendor Complaint Form Documented

                                                                                                                                                                                                    Partcipant Abuse Log Documented
                                                                                                                                     Complaint Form Documented




                                                                                                                                                                                                                                                                              Other written documentation
                                                        Reported by
  Complaint Against                                (Vendor, Participant, Date Reported     Summary of Complaint                                                                                                                                                                                                Comments or Referral
                                                    or clinic staff name)
                            Participant

                                          Vendor




                     All Civil Rights complaints must be forwarded to the Office of Ajudication and Compliance, 1400 Independence Ave. SW, Washington, DC, 20250-9410

				
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