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First Name
Last Name
Address
Telephone / TTY
Mobile phone
Complaint Form
Page 1 of 4Disability Services Commissioner - Complaint Form - Easy English - v1-2011
Tell us what made you unhappy (your complaint)
Page 2 of 4Disability Services Commissioner - Complaint Form - Easy English - v1-2011
Have you spoken to your service (please circle)
What would you like to happen?
What is the name of your service
Yes No
Page 3 of 4Disability Services Commissioner - Complaint Form - Easy English - v1-2011
Your consent
I allow the Disability Services Commissioner to talk to my disability service about what made me unhappy (my complaint).
I do not allow the Disability Services Commissioner to talk to my disability service about what made me unhappy (my complaint).
I would like somebody from the Disability Services Commissioner to call me about my consent
My name is
Signature
or
or
Disability Services Commissioner Level 30, 570 Bourke Street Melbourne Vic 3000
Phone: 1800 677 342 (free call)
TTY: 1300 726 563
Email: [email protected]
Fax: 03 8608 5765
Page 4 of 4Disability Services Commissioner - Complaint Form - Easy English - v1-2011
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