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Message Sacred Heart Grievance Form Name of Complainant: ____________________________________________ Date/Time of Grievance: ___________________________________________Focus of Grievance (please check): ___ Quality of Care (any type of complaint) ___ Access (access to all services) ___ Quality of Practitioner/Office (Site safety, not handicap accessible, etc.)___ Other Description of Grievance: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ ________________________________________ __________________________________ Staff Signature Date Given to Program Director/Rights Advisor Administrative Response: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Decision/Action Plan: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________ _________________________________ Program Director/Rights Advisor Signature Date Signature of the individual enrolled in services Sacred Heart Rehabilitation Center400 Stoddard RoadRichmond, MI 48062810.392.2167