Form for Comments, Compliments, Complaints and Concerns Full Name Contact Details (address / telephone number(s) / email) Details Please include as much detail as possible i.e. date, time, name(s) of staff on duty, relevant conversations □ □ □ □ Comment Compliment Complaint Concern (please tick relevant box) (If necessary, continue on an additional sheets) Sign: Date: □ □ □ Are you Male Female Prefer not to say □ □ 24 and under 45 54 – □ □ What age group do you fit into? 25 34 55 64 – – □ □ 35 44 65 and over – Asian Bangladeshi / Indian / Pakistani / Other – Black African / Caribbean / Other – Chinese Chinese / Other What is your ethnic – background? Mixed (please state) ________________________ Please circle as appropriate White British / Other – Other (please state) ________________________ Prefer not to say Do you consider yourself to □ □ □ Yes No Prefer not to say have a disability?
Form for Comments, Compliments, Complaints and Concerns Full Name Contact Details (address / telephone number(s) / email) Details Please include as much detail as possible i.e. date, time, name(s) of staff on duty, relevant conversations □ Comment □ Compliment □ Complaint □ Concern (please tick relevant box) (If necessary, continue on an additional sheets) Sign: Date: Are you □ Male □ Female □ Prefer not to say What age group do you fit into? □ 24 and under □ 45 – 54 □ 25 – 34 □ 55 – 64 □ 35 – 44 □ 65 and over What is your ethnic background? Please circle as appropriate Asian – Bangladeshi / Indian / Pakistani / Other Black – African / Caribbean / Other Chinese – Chinese / Other Mixed (please state) ________________________ White – British / Other Other (please state) ________________________ Prefer not to say Do you consider yourself to have a disability? □ Yes □ No □ Prefer not to say
Comments%20Compliments%20and%20Complaints%20Form.docx