Complaint Form

Fill out the form below to submit your feedback/concern/complaint.

complaint form

You may file this complaint ANONYMOUSLY, by NOT providing us your name and address. Skip to name and address if you wish to remain anonymous. If you remain anonymous, Z.N.D. RESIDENTIAL, INC. will not be able to contact you to obtain additional information or notify you of the results of the complaint investigation.

Section I Complainant Information

Complete only if you wish to receive our acknowledgment and notification letters with the results of the complaint investigation.

Complainant Name *

Street Address

City

State

Zip

Primary Telephone

Secondary Telephone

Email *

Relationship to program participant

NOTE: All person-identifiable information is confidential.

Section II Facility Information

Facility Name *

Facility Type

Address *

City *

State

Zip *

Telephone

Section III Program Participant Information

Program Participant

Date of Birth

Relationship to program participant

Is the Program Participant still in the facility?

Yes

Additional Name(s):

Name

Date of Birth

Relationship to program participant

Is the Program Participant still in the facility?

Yes

Add Remove

Section IV Alleged Wrongdoer(s) Information - if applicable or known

Name

Title

Additional Name(s)/Title:

Name

Title

Add Remove

Section V Narrative Description:

Provide a narrative description of your complaint which should include date, time and location of the incident. Include name and phone number of any witness(es), if applicable. *

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Complaint Form

Contact Information

Address:

Phone Number

Email

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