Anonymous Incident/complaint Form
Please select the program that is related to your Concern/Complaint.
Head Start/Early Head Start
Housing Program
Loretta Village (Elderly)
Energy Assistance Program
Adult Day Care Program
Loretta Village (Multi-Family)
Tax Preparation Program
Weatherization Program
Other Program
General Concern/Complaint (Not program related)
Date, time and location of the concern/incident you are reporting?
Concern/incident date:
Please enter date in
MM/DD/YYYY
format.
Concern/incident time:
Please enter time in
HH:MM
format.
Name of the site/facility/building:
Street Address:
State:
Zip Code:
City:
Phone Number:
Describe Your Concern:
Provide as much information as you can about your concern, including the date and time of occurrence and any other individuals who were involved.
Name(s) of other people involved and/or affected:
Please list the names of all people who are involved and/or affected by your concern.
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Have you reported this complaint to anyone else, including the Head Start program?
Yes
No
If yes, who did you talk to:
What was the response? Please type the details below. If there was no reponse, please write no response.
What would you like to see happen to resolve your complaint?