Complaint
Form
Name: _________________________________________________________________________
Address: _________________________________________________________________________
City: ________________________ Province: __________ Postal
Code: ____________
Phone
number: _________________ c
Home c
Work c
Cell c
Pager
(include area code)
Phone
number: _________________ c
Home c
Work c
Cell c
Pager
(include area code)
Alternate
Phone number: _________________ c
Neighbour c
Relative c
Friend c
Cell c
Pager
(include
area code)
Do you have a fax number: __________________
(include
area code)
The Ombudsman Office hours of work are Monday to Friday, 8:30am to 4:30pm.
What is the best time for us to call you?
__________________________________________________________________________________
How did you hear about us?
___________________________________________________________________________________
1. Give us the name of the organization you are complaining about. (Please be
as exact as you can be.)
_______________________________________________________________________________
2.
Give us the names of the people
you have dealt with there. Give us any job titles, phone numbers or business
addresses that you have for them.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3.
Tell us your complaint. Tell
us what you have done to try to solve the problem yourself.
(Please give
us any file or reference numbers and the dates these things happened.)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4.
Did you file an appeal or
apply for a review? c Yes
c No
If yes, when was the last appeal or review and what was
the result?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
5.
Why do you believe the
organization's actions are unfair?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6.
What do you want to happen?
Describe the result or outcome.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7.
If you consider the matter
urgent, explain why.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Your signature: _____________________________________ Today’s Date: _______________
Send
complaint form to:
PO Box 9039 Stn Prov Govt Fax:
(250) 387-0198 (