Complaints and Feedback System
Your Details:
Title:
Mr
Mrs
Ms
Miss
Master
Dr
Professor
Given Names:
Last Name:
Organisation:
Address:
Suburb:
State:
Postcode:
Country:
Email:
Phone No:
Fax No:
Mob/Work No:
Do you require an interpreter?
Yes
No
Language/Dialect:
Do you have any special requirements e.g. vision impaired/TTY?
Are you the person affected by the issue?
Yes
No
Other Details:
(If you are representing someone we may need to confirm your authority to act for that person)
Title:
Mr
Mrs
Ms
Miss
Master
Dr
Professor
Given Names:
Last Name:
Address:
Suburb:
State:
Postcode:
Country:
Phone No:
Please indicate why you are representing this person:
Demographics:
Is the person affected by the issue of Aboriginal or Torres Strait Islander origin?
No
Aboriginal
Torres Strait Islander
Does the person affected by the issue come from a culturally and linguistically diverse background?
Yes
No
If yes, please specify:
Is this a disability issue?
Yes
No
The Issue/Feedback:
Feedback Type:
Complaint
Compliment
Suggestion
Feedback Relates To:
Building and Facilities
Business Decision
Legislation and Regulation
Multiple Areas
Other
Products and Services
Staff Issues
Website
What part of the organisation does this relate to?
Division:
Branch:
Section:
What happened and who was involved? (maximum 400 words)
What solution is sought?
Have you raised the issue before?
Yes
No
Are you prepared to be identified to the individuals involved?
Yes
No
Please provide details about the issue:
When:
Where:
What happened and who was involved? (maximum 400 words)
What would your preferred resolution be?
Have you raised the issue before?
Yes
No
Are you prepared to be identified to the individuals involved?
Yes
No
Please provide details about the issue:
When:
Where:
What happened and who was involved? (maximum 400 words)
Have you raised the issue before?
Yes
No
Are you prepared to be identified to the individuals involved?
Yes
No
Please provide details of your suggestion (maximum 400 words):
Have you raised the issue before?
Yes
No
Are you prepared to be identified to the individuals involved?
Yes
No
Should you wish to change any information after it has been submitted you should contact the Feedback Coordinator on 08 6364 6724 and quote the allocated reference number (this is provided after you have selected the "Submit" button).