Complaint Resolution Log Form

     Please answer all questions.

  1. Name of Complainant


  2. ID Number (if any):                 3. Complaint Cell Phone       4. Complaint E-mail


  5. Please Select One. What is this complaint about?


  6. Other Complaint Area.  Please describe:


  7. Complaint Description


  8.  Describe Complaint Resolution


  9.  Date of Resolution:          10. Name of Personnel Responsible:


11. Complainant Notification Date:




12.  Signature of Complainant:   X