Consumer Grievance Procedure & Forms Consumer Grievance Form SECTION A - Person Filing This ComplaintName(Required) First Last Address Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email Preferred method of contact Phone Email Mail In Person Preferred language (if not English)Are you filling on behalf of someone else? Yes - I am filling on behalf of another person No - I am filling for myself If yes - Name of the person you are representing:Your relationship to that person: Family member / Caregiver Legal guardian / Power of attorney Advocate / Attorney Other Other RelationshipSECTION B - YOUR COMPLAINTDate(s) the issue occurred(Required)Which program or service is this complaint about?(Required) Home care Jersey Assistance for Community Caregiving StateWide Respite Program Representative Payee Services Adult Protective Services Volunteer Services Medicare Counseling Operation Sleighbells Other Other program or serviceWhat is the nature of your complaint? (Check all that apply)(Required) Denial of service Reduction or termination of service Quality of service Staff conduct / Treatment Discrimination Privacy violation Delay in service Billing / Financial concern Other Other Complaint TypePlease describe your complaint in detail(Required)What outcome or resolution are you requesting?(Required)SECTION C - STEPS YOU HAVE ALREADY TAKENHave you previously spoken to an FCS staff member or supervisor about this concern? Yes No If yes - who did you speak with, and when?What was the outcome of that conversation?Do you have any supporting documents or evidence (letters, emails, photos, etc.)? Yes - attached Yes - available upon request No File Drop files here or Select files Max. file size: 300 MB. SECTION D - ACCOMMODATION NEEDSDo you need any of the following to participate in this process? (Check all that apply) Language interpretation / Translation Large-print materials Audio format Sign language interpreter Assistance completing this form Other accommodation: Other items needed participateSECTION E - CERTIFICATION & SIGNATURESignatureDate MM slash DD slash YYYY Printed Name of Person Signing Grievance Policy and Procedure for Area Plan Contract Service ParticipantsFCS Grievance Form (PDF)OAA Notice of Privacy PracticesOAA Non Discrimination PolicyOAA Attention all Consumers
