Suggestions and Complaints

	Department of Human Services Suggestion and Complaint Form
Person Reporting
Suggestion
Complaint

Anonymous
Prefix	First Name	Middle Name	Last Name	Suffix

Address		Apt #	Quadrant	Ward

City		State	Zip Code

Phone Number		Email Address

Type of Complaint or Suggestion Related to Program
ADA	Discrimination	Facility & Environmental	Homeless Services/Shelters	Privacy
Customer Service	Eligibility/Benefits	Family Services	ESA/Service Centers	Other


Location of Incident

Facility Name

Street Address		City	State	Zip Code

Date of Incident	Time of Incident
	hrs min am/pm

Persons Involved
1. First Name		Last Name		Phone Number

Address		City	State	Zip Code

2. First Name		Last Name		Phone Number

Address		City	State	Zip Code

3. First Name		Last Name		Phone Number

Address		City	State	Zip Code

Witness(es)
1. First Name		Last Name		Phone Number

Address		City	State	Zip Code

2. First Name		Last Name		Phone Number

Address		City	State	Zip Code

3. First Name		Last Name		Phone Number

Address		City	State	Zip Code


Description