GRIEVANCE REVIEW HEARING REQUEST FORM IDENTIFYING INFORMATION (Provide the following information) Complainant’s name: foster parent; legal parent/guardian, relative/non-relative extended family member Address: Phone: Child’s Case Number: CSW’s Name: Phone: SPA: Office Address: GRIEVANCE (Describe your concerns. Attach additional pages, if necessary) REQUESTED ACTION (Describe how you would like the situation to be resolved) SIGNATURE DATE An explanation of the Grievance Review procedure and instructions are on the reverse of this form. If you need assistance completing this form or have questions about the Grievance Review procedure, contact the DCFS Grievance Review Information Line, (833) 782-0173 or by fax at (213) 427-6154, or by e-mail: DCFS GRIEVANCE REVIEW PROCEDURES California Department of Social Services’ (CDSS) Manual of Policies and Procedures (MPP) Division 31, Section 020 requires a grievance process to review complaints from foster parents includes approved relative and non-relative extended family members caregivers), legal parents, legal guardians and children regarding the placement or removal/replacement of a child or non-minor dependent from a foster home. CDSS also requires that DCFS provide you
GRIEVANCE REVIEW HEARING REQUEST FORM IDENTIFYING INFORMATION (Provide the following information) Complainant’s name: foster parent; legal parent/guardian, relative/non-relative extended family member Address: Phone: Child’s Case Number: CSW’s Name: Phone: SPA: Office Address: GRIEVANCE (Describe your concerns. Attach additional pages, if necessary) REQUESTED ACTION (Describe how you would like the situation to be resolved) SIGNATURE DATE An explanation of the Grievance Review procedure and instructions are on the reverse of this form. If you need assistance completing this form or have questions about the Grievance Review procedure, contact the DCFS Grievance Review Information Line, (833) 782-0173 or by fax at (213) 427-6154, or by e-mail: DCFS GRIEVANCE REVIEW PROCEDURES California Department of Social Services’ (CDSS) Manual of Policies and Procedures (MPP) Division 31, Section 020 requires a grievance process to review complaints from foster parents includes approved relative and non-relative extended family members caregivers), legal parents, legal guardians and children regarding the placement or removal/replacement of a child or non-minor dependent from a foster home. CDSS also requires that DCFS provide you
168815_DCFS4161.docx