Part A – About me

Part B - About the complainant (if different to above)

Fill in this section if you are complaining on behalf of someone else

__________________________

Fill in this section if someone is assisting you with the complaint – for example a family member, your nominee or representative

Part C – Your complaint

Provide some details to help us understand your concerns.  You can include what happened, where it happened and who was involved or the decision made by the Agency that you are unhappy about.

Part D – Who is your complaint about?

Name of the person, or service about whom you are complaining (the respondent or the Agency person who made the decision)

Please attach copies of any documents that may help us investigate your complaint (for example letters, references, emails). 

(For example: a disability service or equal opportunity agency, Health Care Complaints Commission, Ombudsman.)

If so, please provide details of the agency to which you made your complaint and any outcome.  Please also attach copies of any letters you have received from that agency.