Name:     _________________________________________________________________________

Address:  ________________________________________________________________________

City:         ________________________________________________

Province:  ____________      Postal Code:  _______________ 

Contact Phone No:    ______________________   c  Home    c  Work    c  Cell    c  Pager

                                                    (include area code)

Alternate Phone No:  ______________________   c  Home    c  Work    c  Cell    c  Pager

                                                    (include area code)

Fax No:  __________________     

                          (include area code)

The Ombudsman Office hours of work are Monday to Friday, 8:30am and 4:30pm (PST).  Please indicate the best time to contact you, as well as any contact restrictions:

__________________________________________________________________________________

__________________________________________________________________________________

How did you hear about our office?

__________________________________________________________________________________

1.      Which authority (ministry, school, college, or hospital, etc.) is your question or complaint about?

(Please identify by specific name) 

_______________________________________________________________________________

_______________________________________________________________________________

2.      Whom have you dealt with at the authority? 

(List any names, titles, phone numbers or addresses that you have)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

3.      Summarize your complaint and any steps you have taken to try to resolve it:

(Please indicate any file or reference numbers and relevant dates)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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 authority's actions are unfair?

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

6.      Describe the result or outcome that you seek.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

7.      If you consider the matter urgent, explain why.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Signature:  ________________________________               Date: ______________________

Send complaint form to:

PO Box 9039 Stn Prov Govt              Fax:

Victoria, B.C.                                         (250) 387-0198 (Victoria)

V8W 9A5