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ABA Ops Compass

Policies and Procedures

04Sources

Back to Client & Caregiver Complaint Policy

Appendix 29

Grievance Log Form

Active clinic: [Company]

Internal log entry for tracking a grievance from intake through final disposition. Maintained in administrative records in accordance with the agency's record retention requirements.

Log Entry Number

Date Received *

Method

In person
Phone
Email
Written
Other

If Other, Specify

Submitter Name *

Relationship to Client

Self
Parent
Guardian
Caregiver
Other

If Other, Specify

Client name (if different)

Phone

Email

Description of Complaint

Immediate Action Taken (If Any)

Investigation Summary

Resolution and Final Disposition

Date of Final Disposition

Follow-Up Required?

Yes
No

If yes, describe follow-up plan

Sign Off

Staff Member Receiving Complaint *

Date *

Signature *

Sign here

Draw with mouse, finger, or stylus.

Supervisor Review (If Applicable)

Date

Signature

Sign here

Draw with mouse, finger, or stylus.

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