Grievance Follow-up Use this form to document receipt and resolution. Document this report on your Grievance Log. RECEIPT OF COMPLAINT/GRIEVANCE Date received: Resident
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Individual initiating complaint:
Resident representative (Relationship)
Concern reported to: BRIEF DESCRIPTION OF COMPLAINT/GRIEVANCE
FOLLOW-UP Individual(s)/title designated to take action on this concern: Date assigned:
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Date to be resolved by:
Was a group meeting held? Yes
No
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if yes, identify all individuals in attendance:
Was Executive/corporate management involved? __________________________________________________ Describe actions taken for resolution and their results
RESOLUTION OF GRIEVANCE/COMPLAINT Is individual filing grievance satisfied? Yes
No
explain why not: ______________________________
Identify the method(s) used to notify the resident and/or resident representative of the resolution: Written notification
Phone conversation
In-person
Date of notification:
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This form was completed by: (name/position) Executive Director’s Signature: ________________________________________________________________
