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1. Name of Consumer, Family, Guardian or leave blank if Anonymous:

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2. Date of complaint/grievance:

Date

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3. Program/Location:

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4. Subject of Complaint/Grievance:

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5. Please describe the nature of the compliant/grievance: (Required.)

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6. Desired Outcome:

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7. Person completing and/ or filing the complaint/grievance report or leave blank if anonymous:

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8. I have selected someone to be my personal advocate to file this complaint/grievance on my behalf: (Required.)

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9. If yes, who is the person that you have requested or designated to be an advocate on your behalf?

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10. Name of contact for communication regarding complaint:

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11. Contact's Mailing Address:

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12. City

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13. State

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14. Zip code

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15. Contact's Phone number

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16. Contact's Email Address

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