This is a sample form. To use it in the digital world, copy and past it into the comments section of the Contact form.

Complaint Department

Step One: Articulate the problem.

Date:_____________________

 

1.) Chief Complaint: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.) Duration of problem:_____________________________________

3.) Is anyone at fault or to blame? Circle one: Yes / No

4.) *Name or describe the responsible party (*optional): ____________________________________________________________________________________________________________________________________________________________

5.) *Desired Outcome (*optional):
________________________________________________________________________________________________________________________________________________________________________________________________________________

6.) * Proposed Solution (*optional):
____________________________________________________________________________________________________________________________________________________________

7.) Do you want the complaint(s) posted online at onehundredyears.org?
Circle one: Yes / No

8.) Do you want the complaint(s) published in the forthcoming book?
Circle one: Yes / No

9.) Do you want the complaint(s) attributed to you?…….. For the website: Yes / No  …….For the book: Yes / No

10.) Name*:__________________________________________
(*optional – for attribution)

11.) Email address**:_________________________________________
(* *optional – for future opportunities to complain & notification about online posting and book)

Thank you so much for participating!

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