This form contains 4 sections. The sections are for:
- Parents to record their complaint and recommendations.
- The ECE service to record its interpretation and provide its response.
- Parents and the ECE service to record their agreement on a way forward.
- Parents to indicate when the complaint has been resolved to their satisfaction.
Parents and the ECE service should each keep a copy of this form.
Section 1 – Parents to Complete
Parent’s Name/s: ___________________________ Child’s Name: _______________________
ECE Service: _________________________________ Date: ______________________________
Topic of Feedback or Complaint: ____________________________________________________
Full details/Description: ___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I/We propose the following solution(s) or changes: _____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Section 2 – ECE Service to Complete
Our interpretation of this feedback or complaint is: ______________________________________
_______________________________________________________________________________
_______________________________________________________________________________
We propose the following solution(s) or changes in response: _____________________________
_______________________________________________________________________________
_______________________________________________________________________________
Section 3 – ECE Service and Parents to Meet, Discuss, and Complete
Agreed solution/s or changes to be made: ____________________________________________
_______________________________________________________________________________
What will happen now, the name of the person(s) responsible for carrying through each of the agreed actions, and the time frame?
person responsible by what date
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Parent/caregiver: I am satisfied with the way my complaint was received and responded to:
Signature: __________________________ Date: _______________________
ECE service representative: We promise to meet this agreement and will immediately inform you if we have any difficulties in doing so:
Signature: __________________________ Date: _______________________
Section 4 – Follow-up
This section is to be completed by the parent/caregiver at the end of time frame specified in Section 3 ‘what happens now’ above.
Parent/caregiver: I am satisfied with the way my complaint was followed through and it has been resolved to my satisfaction:
Signature: __________________________ Date: _______________________