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This form contains 4 sections.  The sections are for:

1. Parents to record their complaint and recommendations.
2. The ECE service to record its interpretation and provide its response.
3. Parents and the ECE service to record their agreement on a way forward.
4. 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:  _______________________