4054 South Memorial Drive, Suite K
Winterville, NC 28590
Tel 252-561-8112 | Fax: 252-561-7455

Company
Quality Improvement
Resources

Grievance Report
Please be sure to review our Grievance Report Procedure prior to filling out the form.

Name of person making report:
Date Grievance Occured:
Program:
   
Please describe the nature of your grievance (including dates, people involved and location).
Who was grievance reported to (Name and Title):
Date Reported:
How was the grievance addressed (what actions, if any, were taken)?
What are the follow up plans?
How can this situation be avoided in the future?
Additional Comments:
Notification Information:
Name Title/Agency Date/Method
Name Title/Agency Date/Method
Name Title/Agency Date/Method
After you click some submit you will see a 'Thank You' page. Please be patient while that page loads, do not press the back button in the browser.
Website Designed by Mirror Design Solutions, LLC
Copyright 2014 Paradigm, Inc. - All Rights Reserved
HIPPA and Disclosure | Rights and Confidentiality