All grievances/comments/concerns, whether from participants, family members, or otherwise, should submitted online via the form below.

Name of applicable HCBS participant: *

First

Last

Name of person submitting this form: *

First

Last

Contact information of the person submitting this form:

Date and time of occurrence of any applicable incident/event:

Date

Time

Nature of applicable incident/event:

Names of witnesses to applicable incident/event:

Resolution sought, if any:

Submit Grievance