Participant/Community Partner Grievance Form

Public Grievance Form
Date*

MonthDayYear
Date
It is 4D Recovery's goal to maintain a trauma-informed and anti-racist workplace environment. 4D encourages participants and community partners to express any concerns about service-related issues, including disrespectful communication, discrimination, unresolved conflict, and any other concerns related to service delivery.

This grievance form is for individuals to complete if they would like to file a formal grievance. This form will be submitted to Human Resources.

If you would prefer to complete a paper copy of this form, you may request a printed copy from any member of staff.
Your name (optional, please leave blank if you wish to remain anonymous):

First NameLast Name
Please select which department this grievance is in relation to:*

Clinical Treatment ServicesPeer Recovery ServicesResidential ServicesAdministrationOther
Date of grievance/event

MonthDayYear
Date
Describe in detail the nature of your grievance:*
If applicable, did you talk to the staff person directly regarding your concern?

YesNo
Name of the person you first reported the grievance to:

First NameLast Name
Please describe your desired resolution or steps that should be taken to prevent future events like these:
Please describe the steps you took, if any, to resolve this grievance with anyone prior to completing this form:
Would you like a member of 4D leadership to reach out to you?*

YesNo
You may remain anonymous if you wish. However, please leave some method of contact if you would like someone to follow up with you.
Phone Number

Area CodePhone Number
Email
example@example.com
Signature

Clear
Should be Empty:

Public Grievance Form