Have a Complaint? – Choices Association Inc.

This form is for use in the Concerns and Complaints Process at Choices as a record of the unresolved concern or complaint being brought forward. The purpose of this process is to ensure ongoing communication and come to a satisfactory resolution based on our Just Culture and Positive Inquiry Practices. The form is to be completed by the person with the complaint. Please answer the questions below as clearly and concisely as possible. The person reviewing your complaint will contact you within two (2) business days to confirm receipt. The complaint will only be accepted if this form is signed and dated by the person making the complaint. If the complainant is an organization, a signing officer representing the organization must sign and date the Complaint Form. Note: Your contact information will be kept confidential. Please tell us if you have any concerns receiving calls or emails from us. * Required

Date of Complaint or Concern:

Complainant Contact Information: Full Name(Required)

First Last

Name of Organization (if applicable)

Address(Required)

Street Address Address Line 2 City Province

Phone Number(Required)

Email(Required)