Part 1
I would like to bring a complaint to the attention of the Commissioner
for someone else
Has the person who received the service given you permission to make a complaint on their behalf?
Yes
No
The person who recieved the service is deceased
Do you have a legal role for the person who received the service? (for example, parent of a
child under 18, guardian)
No
Yes, please give details
Part 2
Details of the person who received the service
Title
First name
Last (family) name
Date of Birth
Address
Postcode
Daytime telephone number
Mobile
E-mail address
Please let us know about any special needs
I need an interpreter, specify language
I am deaf or hearing impaired
I am Blind or vision impaired
I need help to read and/or write
Other, please specify
age
Please Indicate if you are
Aboriginal
Torres Strait Islander
both Aboriginal and Torres Strait Islander
Language other than English
Yes
No
Part 3
Details of the person who is making a complaint on behalf of the person described in Part 2
Title
First name
Last (family) name
Your relationship to service user
Address
Postcode
Daytime telephone number
Mobile
E-mail address
Please let us know about any special needs
I need an interpreter, specify language
I am deaf or hearing impaired
I am blind or vision impaired
I need help to read and/or write
Other, please specify
Age
Part 4
Details of the service that the complaint is about
Name of service
Name of worker/s involved
Address of service
Daytime telephone number
Please tell us what has led to the complaint, including what happened
When it happened
Details
My main concerns are
How I would like my concerns resolved
Are there any immediate issues that need to be addressed so you can still use the
service while your complaint is being considered?
If yes, please give details, including name and details of person contacted and the outcome
If yes, the outcome
How did you find this form?
If another way, please give details
Part 5
Completion and lodgement
Please read our disclaimer.
Click the button once to lodge complaint
Or
print this form and post it to
HCSCC
PO Box 199
Rundle Mall SA 5000
or fax this form to
08 8226 8620
HCSCC will contact you within three working days of receiving your form to let you know we have received your complaint.
