Community Complaint Register

Company Letterhead

{{company_name}}

{{company_address}}

{{phone}} | {{email}} | {{website}}

Community Complaint Register

Complaint Register Number: {{complaint_register_number}}

Date of Complaint: {{date_of_complaint}}

Time of Complaint: {{time_of_complaint}}

Complainant Details

Full Name: {{complainant_full_name}}

Address: {{complainant_address}}

Contact Number: {{complainant_contact_number}}

Email Address: {{complainant_email_address}}

Preferred Method of Contact: {{preferred_contact_method}} (e.g., Phone, Email, Post)

Are you lodging this complaint on behalf of another person or group? {{yes_no}}

If Yes, please provide relevant details: {{representative_details}}

Details of the Complaint

Date(s) of Incident(s): {{date_of_incident}}

Location of Incident(s): {{location_of_incident}}

Nature of Complaint (Please tick all applicable):

[ ] Environmental (e.g., pollution, noise, waste)

[ ] Infrastructure (e.g., roads, water, electricity)

[ ] Service Delivery (e.g., delays, poor quality, unavailability)

[ ] Staff Conduct (e.g., rudeness, unresponsiveness)

[ ] Policy/Procedure (e.g., unfair application, unclear rules)

[ ] Other (Please specify): {{other_complaint_nature}}

Detailed Description of the Complaint (Please provide as much information as possible, including specific events, impacts, and any relevant background):

{{detailed_description_of_complaint}}

What outcome are you seeking? (e.g., investigation, apology, corrective action, compensation):

{{desired_outcome}}

Have you tried to resolve this issue previously? {{yes_no}}

If Yes, please provide details (who, when, what was discussed): {{previous_resolution_attempts}}

Witness Details (If Any)

Name of Witness 1: {{witness_name_1}} | Contact Number: {{witness_contact_1}}

Name of Witness 2: {{witness_name_2}} | Contact Number: {{witness_contact_2}}

Documents and Evidence Submitted (If Any)

Please list any supporting documents or evidence attached to this complaint (e.g., photos, videos, correspondence, reports):

{{list_of_evidence}}

Note: Do not submit original documents. Please provide copies.

Confidentiality and Privacy

Your personal information will be handled in accordance with applicable data protection laws (e.g., POPIA in South Africa, NDPA in Nigeria). Information provided will be used solely for the purpose of investigating and resolving this complaint.

Do you consent to your identity being disclosed to relevant parties tasked with investigating this complaint? {{yes_no}}

Declaration by Complainant

I, {{complainant_full_name}}, hereby declare that the information provided in this complaint form is true and accurate to the best of my knowledge.

Signature of Complainant: _______________________

Date: {{declaration_date}}

For Official Use Only

Received By: {{receiver_name}}

Date Received: {{date_received}}

Action Taken/Assigned To: {{action_assigned_to}}

Status of Complaint: {{complaint_status}} (e.g., Pending, In Progress, Resolved, Unresolved)

Resolution Date: {{resolution_date}}

Resolution Details: {{resolution_details}}

Follow-up Actions: {{follow_up_actions}}

Signature Block

_______________________

{{authorised_officer_name}}

{{authorised_officer_title}}

{{company_name}}