Online Complaint/Concern Form

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* 1. Please complete the online form below. When finished, select the "Done" button to submit for processing.

Date / Time

Date

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* 2. Contact Information (please verify contact information for accuracy)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Program/Department

Educations/Centers

Mental Health/Wraparound

APP/Child Care Payments

Adminstration

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* 4. I have a

Concern

Complaint

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* 5. Complaint/Concern Type

Payment/Fiscal

Program/Service

Staff Conduct (please include staff person's name in description, if applicable)

Policy/Regulation

Other (please specify)

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* 6. Describe your complaint/concern:

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* 7. Describe your desired expectation/resolution: