Community Action Network Feedback Form
Your feedback is valuable to us as we strive to improve and applaud our services.
Please fill out the form below to submit your feedback.
Contact Information
Full Name
Address
Contact Number
Email Address
I prefer to remain anonymous
Feedback Information
Nature of Feedback (select all that apply)
Accessibility
Communication
Program/Service Quality
Safety
Staff Conduct
Other (please specify):
Is this feedback about an ongoing or a specific occurrence?
Ongoing
Specific Occurrence
Date of Occurrence
Time of Occurence
Please provide a detailed description of the occurrence. Include names of staff involved (if applicable) and any relevant details.
Are there other witnesses of the occurrence?
Yes
No
Please list each witnesses name and contact information
Resolution Questions
Does this occurrence require a resolution?
Yes
No
What would be an acceptable resolution to you?
If deemed appropriate, would you like to be involved in the resolution process?
Yes
No
Other (please explain)
Supporting Documentation
If applicable, please attach any relevant documents or evidence that may illustrate or assist in the investigation of this occurrence. This may include photos, emails, letters, etc.
Select 'choose file' below to upload a document. Select 'add another response' to upload additional documents.
Confidentiality Agreement
By submitting this feeback, you agree that the information provided may be used for investigation purposes. Your identity will be kept confidential to the extent allowed by law.
I agree
Next Steps
Depending on the circumstance, a representative from CAN may follow up with you soon to discuss the resolution or gather additional information if needed.
Contact Information