Grievance Log Template

ADVERTISEMENT
Acknowledgement Letter Provided?
Month: _________
Yes  No  Date: __________
Year: ___
_____
Outcome Letter Provided?
Yes  No  Date: __________
Grievance Log
Date Grievance Filed: ____________
Grievance entered by (Staff person): _ ________________________________________________
Yes 
No  FA/CM Initials: _______
Reported to Facility Administrator/Clinic Manager?
Name of Grievant: __ _______________________________________________________________
Description of Grievance:
___________________________________________________________________________________________
________________________________________________________________________________________
Actions/Steps Taken:
Date:_________ Actions/Steps completed by (Staff person):
Date: __________Actions/Steps completed by (Staff person):
Date:
________ Actions/Steps completed by (Staff person):
Resolution:
Was the grievant provided a verbal explanation of the above resolution?
Yes No 
Date: ___________
Was the Grievance escalated? No
If so to whom: _________________________________________________________________________
*Please attach any documentation regarding the escalation of the grievance.
Acknowledgement Letter Provided?
Month: _________
Yes  No  Date: __________
Year: ___
_____
Outcome Letter Provided?
Yes  No  Date: __________
Grievance Log
Date Grievance Filed: ____________
Grievance entered by (Staff person): _ ________________________________________________
Yes 
No  FA/CM Initials: _______
Reported to Facility Administrator/Clinic Manager?
Name of Grievant: __ _______________________________________________________________
Description of Grievance:
___________________________________________________________________________________________
________________________________________________________________________________________
Actions/Steps Taken:
Date:_________ Actions/Steps completed by (Staff person):
Date: __________Actions/Steps completed by (Staff person):
Date:
________ Actions/Steps completed by (Staff person):
Resolution:
Was the grievant provided a verbal explanation of the above resolution?
Yes No 
Date: ___________
Was the Grievance escalated? No
If so to whom: _________________________________________________________________________
*Please attach any documentation regarding the escalation of the grievance.

Download Grievance Log Template

350 times
Rate
4.3(4.3 / 5) 24 votes
ADVERTISEMENT