Complaint Form

⚠️

Emergency Situation

Please indicate if this complaint involves an emergency situation:

An emergency situation is one that requires immediate attention due to serious risk to health, safety, or property. This includes situations where 911 may have been called or should be called.

Is this an emergency situation? *

Yes

🕵️‍♂️ Submission Type

Would you like to submit this complaint anonymously? *

Yes

👤 Submitter Information

Full Name *

Job Title *

☎️ Contact Information

Preferred Contact Method *

Contact Details *

📅

Complaint Details

Date of Incident *

Time of Incident *

👥 Related Parties

Is this complaint related to a participant? *

Yes

Is this complaint related to an employee? *

Yes

Participant Name *

Type a name and press Enter or , to add. Click × to remove.

Employee Name *

Type a name and press Enter or , to add. Click × to remove.

🧑‍🤝‍🧑 Other Parties Involved

Subjects

If there are multiple people, separate their names with commas.

Witnesses

If there are multiple witnesses, separate their names with commas.

📄 Complaint Details

Complaint Title *

Detailed Description *

📍 Location Information

Address/Location

Use either the dropdown menus or click on the map to select your location. Both methods will sync automatically.

State *

County *

Location Type

Select Location on Map

Click on the map to select your location. State and county will be automatically detected and synced with dropdowns above.

Selected State

Selected County

Location Type

💬 Manager / Program Supervisor Communication

Have you discussed this issue with your Manager/Program Supervisor?

Yes

✅ Resolution

Proposed Complaint Resolution

✍️ Digital Signature

🖊️ Digital Signature *

🖐️ Use your mouse or finger to draw your signature above.

📎 Supporting Documents

Additional Documents

You can select multiple files (PDF, Word, images). Maximum file size: 10MB per file.

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