Source

Full Name

Date

Phone Number

Address

Is there someone else (legal representative or support person) that you would like involved in making this complaint?

Name of legal representative/support person

Name of Person

What is your relationship to that person

Phone No

Does the person know you are making this complaint?

Does the person consent to the complaint being made?

What is your complaint about?( Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved)

Did someone witness the incident? Would they be willing to be contacted regarding your complaint? If so, provide the name and contact details. (Inform the witness that they may be contacted by the organisation to discuss the matter.)

How can we help to fix this problem or complaint?

Signature