Grievance Form

Grievance Form

Waterfall Community Health Center Grievance Form

Name

Name

First

First

Last

Last

Today’s Date

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Phone

Complaint or Grievance

Date of Incident

Recommended Solution

STAFF ONLY (patients do not fill out the section below)

Action Taken

Date Resolved

Quality Assurance Designee Signature

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