New Jersey Department of Military and Veterans Affairs

New Jersey Veterans Memorial Homes

RESIDENT GRIEVANCE and REFERRAL FORM

Instructions: To initiate this process, please check if this is a grievance, a concern, or a referral request, complete items 1, 2, and 3, provide a brief description of the grievance or concern, sign and submit the completed form to the assigned Unit Manager for follow-up.

[ ] Grievance [ ] Concern [ ] Referral

1. Name of Resident:________________________________________ Unit / Room:________________ Date:____________

2. Submitted by: [ ] Resident [ ] Family [ ] Staff [ ] Visitor [ ] Volunteer [ ] Other

3. Statement: _________________________________________________________________________________________

____________________________________________________________________________________________________

Signature of Person Filing Grievance:_______________________________________________ Date:________________

4. Investigation: Responsible Dept.:___________________ Person:_________________________ Date Rec’d:__________

5. Findings / Decisions: _________________________________________________________________________________

____________________________________________________________________________________________________

6. Recommendations / Actions: __________________________________________________________________________

____________________________________________________________________________________________________

[ ] Grievance or Concern addressed to my satisfaction. [ ] Forward Grievance or Concern to VMH Administration.

Date:_____________ Initials:____________________ Date:_____________ Initials:_______________________

Signature of Resident:________________________________________________ Date:_____________________________

Signature of Investigating Staff Member: _____________________________________________ Date:__________________

04-02-009A –July 2007