Complaints and Feedback Complaints Form Step 1 of 4 25% Section BreakMy feedback is a*IncidentComplimentAccidentComplaintSuggestionI am a:*Thrive365 ParticipantThrive365 RelativeService ProviderThrive365 StaffYour Client IDPlease provide your Thrive365 Client ID (if you know it) Which service or team of Thrive365 are you writing about?We encourage you to raise issues with the relevant member of staff providing the service in the first instance.Date of Incident* Time of Incident* : HH MM AM PM Have you discussed the issue with the relevant service?YesNoDid the incident occur during service delivery?*YesNoWere there any witnesses of the incident?*YesNoWitness NameWitness PositionWitness Email Witness Phone NumberWere other clients involved or witness the incident?YesNoClient NameClient Email Client Phone Number What would you like to tell us?*If you have any further documents relating to your feedback can you please email them to email@example.com.What would you like to happen now?Please provide details of the matter (if insufficient space above) Would you like a response to your complaint/feedback?YesNoNameIf 'Yes' please provide your contact details: Note: You may make a complaint anonymously if you prefer though you will not receive a response and if you do not provide enough information, we may not act on, or be able to resolve your complaint or concerns. First Last Feedback provided on behalf ofAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email Contact Phone NumberSignatureDate I prefer contact byPhoneEmailLetterN/AImportant NoticeNote your feedback will go to Thrive365’s feedback email which will be forwarded to the relevant Business Area. We will keep your personal information confidential as far as possible. However, there may be some circumstances when your personal information will need to be provided to others as part of the process of addressing your complaint. Personal information may also be released under the provisions of the Privacy Act 1998 and may be subject to release under the Freedom of Information Act 1989. We will keep this form as part of our Directorate records. The Directorate collects, manages, uses and discloses personal information under the requirements of the Information Privacy Act 2014 and the Health Records (Privacy and Access) Act 1997.