Complaints and Feedback System  

      

Your Details:
Title:   
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:   
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:   
Feedback Relates To:   
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).