Scribd
Upload
755 views4 pages

Template Form Compliments and Complaints Management

The document provides a template for a compliment and complaint form that can be used by organizations to collect feedback from clients in a structured way. The form collects key details about the person providing feedback, the service the feedback is about, the nature of the feedback, actions already taken, desired outcomes, and a declaration. It aims to facilitate the effective management of feedback by recording important information at the initial point of contact.

Uploaded by

intan fajriyah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
755 views4 pages

Template Form Compliments and Complaints Management

The document provides a template for a compliment and complaint form that can be used by organizations to collect feedback from clients in a structured way. The form collects key details about the person providing feedback, the service the feedback is about, the nature of the feedback, actions already taken, desired outcomes, and a declaration. It aims to facilitate the effective management of feedback by recording important information at the initial point of contact.

Uploaded by

intan fajriyah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 4

Compliment and complaint form template

An effective feedback, compliment and complaint handling system addresses the principles of visibility
and accessibility, responsiveness, assessment and investigation, feedback, improvement focussed
and service excellence.
The compliment and complaint form template is a tool to facilitate feedback being heard clearly and
effectively managed by recording key information at the time of first contact.
A listing of support available from the Department of Health and Human Services, the Department of
Education and Training and other organisations in the form of training, advice and resources for
receiving and managing compliments and complaints is provided.

[SERVICE NAME]
[INSERT SERVICE LOGO]
Our service is committed to providing high quality care and services and meeting your needs. We
value your feedback – including complaints.
Please let us know what we do well and where we can improve our services.
Indicate your response below with an X.

This is a: compliment complaint feedback

Section 1: Your details


Do you want to remain anonymous? (Indicate your response with an X)

yes no

Personal details
First Name:

Last Name:

Postal address:

Telephone number:

Mobile number:

Email address:

Do you require an interpreter?

yes no If yes, which language?

Are you providing feedback on another person’s behalf? (Indicate your response with an X)

no (go to Section 4) yes

Compliment and complaint form template Page 1 of 4


Section 2: Feedback made on another person’s behalf
Please provide the following details about the person on whose behalf you are acting:

First Name:

Last Name:

Postal address:

Telephone number:

Mobile number:

Email address:

Please provide details of your relationship to the person on whose behalf you are acting:
Are you a legal representative for the person who received the service?
(e.g. parent of a child under 18 years or guardian – indicate your response with an X)

yes no

If yes, please provide details:

Does the person know you are making a complaint on their behalf? (Indicate your response with an X)

yes no

If no, please provide the reason why:

Are we able to speak with the person who received the service? (Indicate your response with an X)

yes no

If no, please provide the reason why:

Compliment and complaint form template Page 2 of 4


Section 3: Other person’s consent for feedback
made on their behalf
If you are providing this feedback on another person’s behalf, we require the consent of the other
person to obtain and pass on personal information relevant to this feedback. Please provide evidence
of this consent when submitting this form, e.g., signed consent (as provided below) from the person on
whose behalf you are acting.
I, (insert name of person giving consent) give permission to (insert name of person receiving consent)
to provide or collect relevant information on my behalf to assist with this complaint/compliment or
feedback, as necessary.

Signature: Date:

Section 4: Please provide details of the service that the


feedback concerns
Name of the service provider:

Address of office location of service:

Contact person’s name and position in the service:

Section 5: Please state your concerns


Please provide details of your main concerns, including what events led to making the complaint,
compliment or feedback, approximate dates and who was involved.

Section 6: What action have you already taken in relation


to this feedback?
Have you discussed your concerns with the service provider or another agency or person for
assistance with these concerns? (Indicate your response with an X)

yes no

Compliment and complaint form template Page 3 of 4


If yes, with whom and what was the outcome?

Section 7: What outcomes would you like as a result of


providing your feedback?

Section 8: Privacy
The (name of funded organisation) is committed to protecting your privacy. We collect and handle
personal information that you provide on this feedback form for the purpose of investigating and
responding.
The (name of funded organisation) will only use your information in accordance with relevant privacy
and other laws. In order for us to provide services to you effectively and efficiently, we may need to
share your personal information with others, such as (insert) that deals with the matters identified in
your feedback.
If you choose to remain anonymous, (name of funded organisation) may be unable to deliver the full
range of services you require.
If you wish to contact (name of funded organisation) who are responsible for managing the personal
information that you provide on this form, please call (insert contact phone number).
You also have the right to access your information and seek its correction under the Freedom of
Information Act 1982. For information about making a Freedom of Information application contact
(insert name) on (insert contact phone number).

Section 9: Declaration
Paragraph declaring information provided is true and correct.

Signature: Date:

Thank you for taking the time to provide feedback about our service.

Compliment and complaint form template Page 4 of 4

You might also like