Complaints Form Question Title * 1. Please select the DVAC site your complaint relates to Ipswich Region Service Toowoomba Region Service Question Title * 2. Date: Date Question Title * 3. Details of person making the complaint: Name Contact Number Question Title * 4. Client or stakeholder? Client Stakeholder Question Title * 5. Program complaint is in relation to: Administration Family Counselling Children/Young People Counselling Crisis Response Program Safety Upgrades Program Court Support Management Community Development Sexual Violence Program ReNew Unknown Other (please specify) Question Title * 6. Please provide details of person/s complaint is in relation to (if known): Name Role/Position Description Name Role/Position Description Question Title * 7. Details of complaint (please include dates and specific details around circumstance(s) that have led to the complaint): Questions below are for office use only: Question Title * 8. Details of investigation and response (please include dates and specific details around the plan for resolution and the actions taken): Question Title * 9. Details of person receiving the complaint: Name Role Question Title * 10. Date complaint received: Date Question Title * 11. Signature of CEO: Signature Question Title * 12. Date CEO received complaint: Date Thank you Done
