Compliment and Complaint

PERSONAL DETAILS

First Name*

Last Name*

Postal Address

Postcode

Email*

Phone No

Mobile No

COMPLIMENT

Tell us

COMPLAINT

Have you lodged a complaint with Prime 1 Care before?

YES (If yes, was the matter resolved?)

NO (Comments)

Is there someone else (legal representative or support person) that you wish to involve in making this complaint?

If yes, what is the name of legal representative/support person?

Postal Address

Phone

DETAILS OF THE COMPLAINT

Is the complaint referring to:

Details

What happened?

When did it happen? (Include date if possible)

Where did it happen?

Who was involved? (List all personnel and witnesses involved)

Was there an individual that witnessed the event?

Would they be comfortable being contacted regarding this complaint?

If so, provide the name and contact details. (Inform the witness that they may be contacted by the organisation to discuss the matter.)

Any other relevant details or comments

Have you discussed the matter with the person/s involved?

If yes, what was the outcome, if any?

Please attach a copy (not the original) of your complaint to the respondent and any letter of reply you have received.

If no, are there any reason/s that you cannot do so?

Do you need help to do this, e.g. for safety reasons, cultural reasons?

How do you wish to see your complaint resolved?

What actions are you hoping for Prime1Care to take in order to assist in resolving your complaint?

ADDITIONAL INFORMATION/SUPPORTING DOCUMENTATION

Please attach copies (not the original) of any documents that may help us to handle the complaint, e.g. if you have letters, emails or faxes or records of conversations you have had with the person/s associated with the complaint.