Grievance

Contact Information *

Complaint/Grievance Information

Not treated with respect

Discrimination

Harassment

Felt Unsafe

Privacy/Confidentiality

Problem with staff

Other (Please specify)

Details of event leading to the complaint *

When did the event/action occur? Please provide date, time and location details.

Who was involved *

Please include names and/or description of person(s) involved. You can provide contact details if wish for us to contact them.

What happened

In your own words, please describe the events that have led you to make this complaint/grievance.

Have you spoken to your Probro worker about this?

Yes, what happened and why were you not satisfied with the response.

As a result of your complaint/grievance, what outcomes or actions would you like to see occur.

(check the box) I acknowledge that I have read this document and understand my obligation to provide information as needed and to cooperate with any inquiry of this complaint/grievance. Should it become necessary, I authorize Probro to disclose details of this complaint to the necessary parties unless specified above.

Grievance

Thank You!