QRMHA Complaint Form (Quinte Red Devils)

QRMHA Complaint Form

Please note: 1. QRMHA cannot guarantee complete confidentiality. The contents of this document may be shared to resolve the complaint here within. 2. By completing the form, you agree that QRMHA may share some or all of this information in the process of resolving the complaint. 3. Complaints will be addressed according to severity, resources and safety for participants.

I. Person making the Complaint

2. Name:^*

Required

(Type in your first and last name)

3. Street Address^*

Required

( 123 Maple St)

4. City / Town^*

Required

5. Postal Code:^*

Required

A2B 3C4

6. Cell Number^*

Required

7. email address^*

Required

[email protected] (This email address will receive a receipt / acknowledgement of your submission.)

II. Person on whose behalf the complaint is being made:

(to be completed if different from above)

8. Name:

9. Birth Date:

January 25, 2010

III. Name of Person(s) against whom you are complaining:

10. Name:^*

Required

11. Title / Role:^*

Required

12. Team^*

Required

13. Name:

14. Title / Role:

15. Team:

16. Have you discussed this matter with the person against whom the complaint is being made?^*

Required

(Yes / No - brief explanation if possible.)

17. What resolution is being sought?^*

Required

18. When did this incident occur?^*

Required

19. Please check the box that best describes your complaint.^*

Required

IV. Details of the Complaint

Provide a summary of the incidents you are complaining about. Your summary must answer the following questions. You will be able to attach additional documents as necessary.

20. What happened? ^*

Required

21. Where did the incident(s) happen?^*

Required

22. Who was involved (Title & role)?^*

Required

23. How were you treated differently from others (if at all)?^*

Required

Please feel free to attach any additional documents you feel will assist in understanding this complaint.

Allowed extensions: .jpeg, .jpg, .png, gif, .pdf, .doc, .docx, .xls, .xlsx, .ppt, .pptx.
Maximum # Files: 5. Maximum File Size: 4MB.

24. How do the incident(s) relate to your selection in Question 19 (List of Complaints)^*

Required

25. What remedy/resolution are you seeking?^*

Required

QRMHA Complaint Form (Quinte Red Devils)

OMHA Digital Network

I. Person making the Complaint

II. Person on whose behalf the complaint is being made:

III. Name of Person(s) against whom you are complaining:

IV. Details of the Complaint

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