Complaint Form - Department of Health & Human Services · Tell us what made you unhappy (your complaint) Disability Services Commissioner - Complaint Form - Easy English - v1-2011

First Name

Last Name

Address

Telephone / TTY

Mobile phone

Email

Complaint Form

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Tell us what made you unhappy (your complaint)

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Have you spoken to your service (please circle)

What would you like to happen?

What is the name of your service

Yes No

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Your consent

I allow the Disability Services Commissioner to talk to my disability service about what made me unhappy (my complaint).

I do not allow the Disability Services Commissioner to talk to my disability service about what made me unhappy (my complaint).

I would like somebody from the Disability Services Commissioner to call me about my consent

My name is

Signature

or

or

Disability Services Commissioner Level 30, 570 Bourke Street Melbourne Vic 3000

Phone: 1800 677 342 (free call)

TTY: 1300 726 563

Email: [email protected]

Fax: 03 8608 5765

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