Feedback, Compliments and Complaints Form

Feedback, Compliments and Complaints Form
Enter Authorisation to Continue
This form can be completed electronically or by hand and emailed to feedback@bigbrownhouse.com.au or posted to PO BOX 141 Stockton NSW 2295. Alternatively, you can contact us directly to lodge your feedback, compliment or complaint on 0437 223 164.
Date of Complaint/ Compliment/ Feedback received:*

DayMonthYear
Date
Feedback Received or Made by:
How Was Feedback Made?*
Please Select From The Dropdown

Details of Complaint/ Compliment/ Feedback
Name:*

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/Mobile:*
Email*
example@example.com
Company:
Position:
Does the person making the complaint wish to remain anonymous?

YESNO
Association with BBH:*
Other:*

Complaint/ Compliment/ Feedback Details
Description of Complaint/ Compliment/ Feedback:*
(Including time, place, people involved)
How Would Complainant Like to See This Resolved:

**Office Use Only (enter authorisation to continue)
Was an Incident Form Completed?*

YesNo
Date:*

MonthDayYear
Date
Is external notification Required?*

YesNo
Date:*

MonthDayYear
Date
To:*
Program Manager Notified:*

YesNo
Date:*

MonthDayYear
Date
Acknowledgement Letter Sent:*

YesNo
Date:*

MonthDayYear
Date

Action to be Taken
Actions Proposed:*
Assigned To:*
Required by:*

MonthDayYear
Date

Actions Taken:*
Completed By:*

First NameLast Name
Date:*

MonthDayYear
Date
Outcome
Status of Feedback:*

ResolvedUnresolved
Complaint resolved (how)*
Date*

MonthDayYear
Date
Date of Outcome Letter Sent to Complainant:

MonthDayYear
Date
Specific Proposed Action*
Should be Empty: