If you believe that one of your rights has been violated, you may use this form to file a formal grievance. The STVCC Compliance and Accreditation Manager will review all submitted grievances and may conduct an investigation.  You will be notified in writing the results of the investigation.  Please contact Cliff Levitt, STVCC Compliance and Accreditation Manager at (517) 323-4734 or by email at levittc@stvcc.org for any questions.

I. To be completed by the STVCC client filing the Complaint/Grievance

Client's First Name (required)

Client's Last Name (required)

Client's Address

Street

City

State

Postal Code

Children's Home Unit Name

Client's Phone Number (required) (Ex: XXX-XXX-XXXX)

Client's Email Address (required)

II. To be completed by the person filing the complaint/grievance on behalf of the client (if applicable)

First Name

Last Name

Relationship to Client

Address

Street

City

State

Postal Code

Children's Home Unit Name

Phone Number

Email Address

III. Complaint/Grievance Information

Date of the Alleged Violation (required)

Location of the Alleged Violation (required)

What right was violated? (required)

IV. Complaint/Grievance Description

Is this complaint/grievance about a STVCC staff member? (required)
YesNo

If YES, name of STVCC staff member:

Please Describe What Happened (required)

What would you like to see happen in order to correct the problem? (required)

V. Acknowledgement

I declare that all statements contained in this submission are true and that any misrepresentation or omission may result in rejection of my grievance
YesNo

Typing my name in the box below certifies my signature and submission of my grievance.

Client Signature (required)

Date (required)

Name of person assisting client (if applicable)