Page 30 - CCS Polices and Procedures

Crew Consulting Services
Policies and Procedures
Appendix A: Complaint/Grievance Report Form

Crew Consulting Services LLC is committed to receive, review, and resolve complaints and grievances from
individuals, families, guardians, legal representatives, providers, and other stakeholders in a timely manner. All
complaints and grievances will be addressed promptly, investigated as appropriate, resolved and the outcome will
be communicated to the individual filing the complaint. No one will be retaliated against or otherwise denied care
of services for filing a complaint or grievance.

Date of complaint/grievance Person making the complaint/grievance:

Complainant: Individual CCS Contractor Family Provider Regional Office___________

Nature of Complaint/Grievance:

Action taken by CCS (include all notifications):

Completed By:

Print Name Title Signature Date

*Make complainant aware they should have a response with 5 business days of complaint.

Version Date: 6/23/2018 Page 30 of 33