Provider Monthly Grievance Report

Provider Monthly Grievance Report

Please utilize the below form to report on the number of grievances your program has received and investigated during the reporting month.

Please note that completion of this report is required on a monthly basis even if your program has not received any grievances for the month.

This report is due by 5pm on the 10th of each month for the preceding month. For an example, the Grievance Report for the month of November will be due by December 10th.

Provider Name*

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Program Name*

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Month of Completion*

This report is always due the 10th of every month for the preceding month. The "Month of Completion" should reflect the month that you are completing the report for. For an example, the report for December will be due by January 10th so the "Month of Completion" would be December and not January.

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Year of Completion*

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Number of Grievances Received*

Please indicate the number of grievances that your program has received during the reporting month.

Number of Grievances that Required Investigation*

Please indicate the number of grievances that your program has received during the reporting month that required investigation.

Number of Grievance Investigations Pending Outcomes*

Please indicate the number of grievances that required investigation that are pending outcomes.

Number of Grievance Investigations that have been closed*

Please indicate the number of grievances that required investigation that have been successfully closed and addressed.

Grievance Reports Upload

Please upload copies of all consumer grievance reports received during the reporting month.

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