Complaints/Concerns

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Full Name*
First Last
Email Address*
Phone/VP
Phone Type
Address
Street Address Address Line 2 City State ZIP Code
Your Grievance
A grievance is a complaint made by a client or a community member against a service, staff or policy of GLAD. A grievance must be made within 30 days of the incident. If you cannot complete this form, you may request a meeting with a program manager or CEO who will complete the grievance form for you.
State Your Message*
Submit the date, time and place of incident
Date*
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Location
Name(s) of Staff involved, if any
Names of witnesses or other persons involved
What actions do you want in response to your grievance*
- Select All
- Change in service or policy
- Establish new service or policy
- Attention to staff performance
- Other
Comments
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Complaints/Concerns

Complaints/Concerns

Your Grievance