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Fill and Sign the Medical Certificate Rule 117 Form

Fill and Sign the Medical Certificate Rule 117 Form

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PANHANDLE HEALTH DISTRICT CUSTOMER SERVICE COMPLAINT FORM DATE RECEIVED: RECEIVED BY: COMPLAINANT: METHOD DIVISION/SERVICE: 1) 2) 3) 4) SUPERVISOR REFERRED TO: PHONE IN PERSON BY LETTER OTHER ( ( ( ( ) ) ) ) NAME: CITY: HOME PHONE: STATE: ZIP: WORK PHONE: SEPTIC PERMIT No. or FOOD ESTABLISHMENT: (if Env. Health Related) OTHER: CIRCUMSTANCES SURROUNDING COMPLAINT: (To be completed by appropriate supervisor only) Name of Staff Involved: Date of Initial Contact: Date of Last Contact:____________________________ COMPLAINT: INVESTIGATION: CUSTOMER SERVICE COMPLAINT – Form #PHD-101 COMMENTS / FINDINGS (Include staff input): MANAGEMENT DECISION: Division Director Signature: Date: District Director Signature: Date: Date Completed: Time Spent: Customer Service Complaint Procedure (Policy 1-3) Purpose: This is primarily intended to address complaints received from our clients that relate to staff or program delivery issues. 1. The staff person who is first contacted can complete the top portion (complainant section) of the complaint form. 2. Supervisor contacts the complainant and thoroughly completes the complaint form. 3. Supervisor investigates the complaint, documents the efforts taken to research the issue, and describes how the issue was resolved. 4. The completed form is submitted to the division director for action if necessary. 5. The completed form will then be forwarded to the District Director.

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