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     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