Feedback Form Enquiry, Feedback, Compliment Or Complaint Please choose from the options below: * Enquiry Feedback Compliment Complaint Before lodging a complaint If your complaint relates to an organisation funded by DSS we strongly recommend that you try to resolve the matter before you contact us. Have you approached the service provider about this complaint? - None -YesNo My Details Title - None -MrMsMrs Your Name * Please enter your name as First Middle Last State/Territory * - Select -Australian Capital TerritoryNew South WalesNorthen TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Email address Do you have any special requirements we need to be aware of in order to manage your request? My Preferred Language AfricaansAlbanianArabicArmenianAssyrianAustralian Aboriginal LanguageBantuBengaliBulgarianBurmeseCantoneseChineseCroatianCzechDanishDariDutch/FlemishEnglishEstonianEthiopianFijianFilipino/TagalogFinnishFrenchGeorgianGermanGreekHawaiianHebrewHindiHokkienHungarianIcelandicIndonesianIranian/Persian/FarsiIrishItalianJapaneseKhmer/CambodianKoreanLaoLatvianLebaneseLithuanianMacedonianMalayMalteseMandarinMaoriMongolianNew GuineaNorwegianPakistani/UrduPolishPortuguesePunjabiRomanianRussianSamoanScottish GaelicSerbianSerbo-CroatianSignSinhalese/Sri LankanSlovakSlovenianSpanishSudaneseSwahiliSwedishTagalogTamilTelaguTeochewTetumThaiTonganTurkishUkrainianUzbekVietnameseWelshYiddish Address Details Preferred Contact Method * Email Mail Home phone Mobile phone Work Phone Address Suburb Post Code Home Phone Mobile Phone Work Phone Complaint Details Please provide details of your complaint, including who provided the service. Please enter the details of the organisation or person you wish to complain about. (Include the name, address and contact details if known) Use the space below to provide a short summary of your complaint. It is useful to include what happened, when it happened and who was involved. If you need more space, please attach separate documents below or send an email to complaints@dss.gov.au. * The main key concerns/issues I want looked into are: Issue #1 (No more than 100 words). Issue #2 (No more than 100 words). Issue #3 (No more than 100 words). If you would like to submit more details about your complaint and the issue of concern, you can upload more information below. Files must be less than 2 MB.Allowed file types: jpg jpeg rtf pdf doc docx xls xlsx. Note: If you have more attachments to include, please email them to complaints@dss.gov.au after submitting this form. Please quote the lodgement number your receive after submitting this form. The desired outcome I would like from my complaint is: Consent and Authorisation It would assist the Department of Social Services to have your privacy consent for the purpose of undertaking your complaint. You may choose to remain anonymous; however it is important to note that without your consent it will be difficult for the department to comprehensively address your concerns. I give consent to the Department of Social Services to disclose my personal information to any individuals or organisations, including third parties, involved in the complaint for the purposes of looking into and reporting on my complaint. Yes No I also give my consent to any individuals or organisations involved in the complaint to disclose my personal information to the Department of Social Services for the purpose of looking into and reporting on my complaint by the Department. Yes No I wish to remain anonymous Yes No If you are under the 18 years of age you will need to supply your parent/guardian details below I am the parent/guardian of the person making the complaint Yes No Parent/Guardian Details Title - None -MrMsMrs Your Name * Please enter your name as First Middle Last Preferred Contact Method For Parent/Guardian * Same as above Email Mail Home phone Mobile phone Work Phone Address Suburb Post Code Email address Home Phone Mobile Phone Work Phone The Department of Social Services is collecting information about you to assist in the effective management of your complaint as well as for training purposes. The DSS Privacy Policy has been prepared in accordance with the Australian Privacy Principles and contains information about how you can access and correct personal information held by DSS about you. It also contains information about how you can complain about a breach of the Australian Privacy Principles and how DSS will deal with such a complaint. The DSS Privacy Policy can be found on our website at www.dss.gov.au/privacy-policy. Feedback Details Please provide ALL relevant information in relation to this matter. All information is beneficial in allowing us to determine the next steps for handling the matter. Details If you would like a copy of this information, please print BEFORE you submit the application. Leave this field blank Last updated: 7 June 2017 - 4:07pm
