DCC Complaint Form

Compliant Submission Form

This Complaint Submission Form is intended for use by foster parents, clients, employees, youth, network providers, and other stakeholders associated with DePelchin Children's Center. It should be completed by any individual or organization wishing to formally report a concern or issue related to services, safety, communication, policy compliance, or overall care. The information provided will assist DePelchin Children's Center in reviewing the concern, ensuring appropriate follow-up, and supporting continuous improvement.
Complaint Information
Name of Person Submitting Complaint*
Provider/Agency Name (If Applicable)
Role/Title:*

ClientEmployeeChild/Youth (If Applicable)Foster ParentStakeholderOther
Phone Number
Format: (000) 000-0000.
Email Address*
example@example.com
Client/Case

Only complete this section if your complaint involves a specific child, youth, or case.
Client Name Initials
Child DFPS Person ID if known
Placement Type
Current Caregiver (if applicable)
Complaint Details
Date of Incident or Concern*

MonthDayYear
Date
Location of Incident*
Type of Complaint:*

Safety ConcernSupervision IssueCommunication/ResponsivenessPlacement Process IssueDocumentation/Records IssuePolicy/Procedure ConcernProfessional ConductService DeliveryOther
Description of Complaint
Provide a detailed description of the issue or concern. Please include what occurred, who was involved, and any relevant background.*
Actions Already Taken
Describe any steps your program has taken so far (if any)?*

No action taken yetInternal review completedStaff Involved have been notifiedSafety measures implementedOther actions taken
If other actions have been taken, please describe.
Supporting Documents
Please attach any documentation that may assist DCC in reviewing your complaint.

Cancelof
What type of documentation has been uploaded?

Internal incident reportsEmail correspondenceScreenshotsWitness statementsPolicy referencesPhotos (if appropiate)Other
Requested Outcome or Resolution
Please describe what outcome you are seeking or what you believe would resolve this issue.*
Submission

I certify that the information provided is accurate to the best of my knowledge.
Name*
Signature*

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Date Submitted*

MonthDayYear
Date
Please direct all questions to DCC-complaints@depelchin.org
Should be Empty:

Compliant Submission Form

Complaint Information

Client/Case

Complaint Details

Description of Complaint

Actions Already Taken

Supporting Documents

Requested Outcome or Resolution

Submission

I certify that the information provided is accurate to the best of my knowledge.