Youth Services Grievance

List the name of the facility/shelter provider or the name of the person you have a concern with:*

List the address or city of the facility/shelter provider (if unknown, describe approximate location):*

If known, list the telephone number of the facility/shelter:

When did this concern occur? If you know the date, please enter MM/DD/YY*

Describe what happened (see below for details that should be included): NOTE: The grievance monitor must have enough details about the situation to determine intervention next steps. When providing details about your concern, think in terms of sharing.

WHO– Who is involved (name of program, staff person, or names of child or children, etc.)*

WHAT– What happened to you, a child or children; be specific about what occurred.*

WHERE– Where did this happen (at the facility, a park, in what specific classroom, bedroom, bathroom, etc.)*

WHEN– When did this happen (date, time of day, during class or lunch time, etc.) — Was this the first time it happened? If not, how many times has this happened? How long has it been happening?*

HOW– Describe in detail how it happened and how you found out about this issue if it happened to someone other than yourself.*

Did you report your concern to any other person?*

Yes

If yes, who did you report it to?

Facility/Program Staff

Administrator

Case Manager

Local Police

Child Protection Services

Family Service Specialist (FSS)

Juvenile Correction Agent (JCA)

Parent / Family Member / Guardian

Other – if you have reported it to someone else, please state their name below.

If reported to more than one person, please provide each person's name (first & last name) below. What is their phone number?

Where (what city) is the person you reported to located?*

When did you report your concern? (MM/DD/YY)*

How did you report your concern?*

In Person (face to face)

Phone Call

In Writing (email or letter)

Other

How often do you have contact with this facility/shelter?*

Daily

Weekly

Monthly

Never

How do you know the facility/shelter provider involved in your concern?*

I am a current resident of the facility/shelter program

I am a former resident of the facility/shelter program

I am a current employee of the facility/shelter

I am a previous employee of the facility/shelter

Facility/shelter provides care for my child

Facility/shelter provides care for a friend or relative of mine

I am a Mandated Reporter/Professional

I don’t know the provider, I witnessed this incident

Other

Is there anyone else who might have knowledge of this concern that we should contact?*

Yes

If yes, what is the person's name?

If yes, what is the person's phone number? (If you know it.)

Taking the time to tell us your concerns is very much appreciated. The name of the person making a complaint is not provided to the facility/shelter when addressing the complaint. If the facility/shelter attempts to guess who made a complaint, the grievance monitor will not confirm or deny who made the complaint. If there is not enough information provided on this complaint form, we may not be able to address your concerns. For purposes of obtaining more information or clarifying the details you have submitted, please list your contact information below:

Your Name*

First Last

Your phone number:

Your email address:

Contact Us

Youth Services Grievance

Submit A Quality of Care Complaint