Grievance Form

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Habitat for Humanity East Bay/ Silicon Valley, Inc. ("Habitat" or "We") strives to provide the best services we can through our Home Preservation Program ("Program"). We value your feedback and want to hear from you if you have a concern about how your application was reviewed or about the Program so that we can improve the Program for you and future applicants.

Please note that there are different procedures for specific types of concerns. See chart below.

Types of Concerns

Timeline to Submit Concern

You are dissatisfied with the way your project is being handled

You feel you were denied reasonable accommodations

Submit a grievance form to Habitat no later than sixty (60) days after the decision, incident, or violation has occurred.

Please fill out the grievance form. Process outlined below

Appealing a Denial Letter

Do not fill out grievance form below

Submit your appeal letter within three (3) weeks from the date of the denial letter.

Process outlined in Denial Letter. Do not fill out grievance form below.

You have a dispute with the Contractor for your Project (about work or payments)

Do not fill out grievance form below

Notify Habitat staff within five (5) days.

For Grants, process outlined in the General Provisions associated with the Scope of Work.

For Loans, process outlined in Article 32 of your Construction Contract.

Section 1: Contact Information

First Name

Last Name

Street Address

City

State

Zip Code

Phone and Email

Preferred Method of Contact

Primary Phone

Format 999-999-9999

Alternate Phone

Format 999-999-9999

If you are filling this form out on behalf of someone else, please list your contact information below

First Name

Last Name

Relationship to Applicant

Email Address

Phone Number

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Section 2: Complaint Details

When did the decision, incident, or violation occur (MM/DD/YYYY)?

Please select one or more of the complaint categories below.

#1: I am dissatisfied with the way my project is being handled.#2: I was denied a reasonable accommodation for equal access to programs, services, and/or activities e.g.: physical, programmatic, and/or communications. #3: Other

Please describe the decision, incident, or violation in detail, providing names where possible of individuals involved.

How would you like this to be resolved?

The following additional details are required if you selected #3 reasonable accommodation above.

Have you previously filed a complaint regarding this issue with Habitat or another organization?

YesNo

If yes, name of Agency

If yes, date filed (MM/DD/YYYY):

If yes, contact person:

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Section 3: Process and Timeline

Step in the Process	Timeframe
Step 1: Submit Grievance Form	Applicant submits form within sixty 60 days from date of issue/concern.
Step 2: Habitat Acknowledged Receipt for Grievance and Starts Review	Habitat will send you a confirmation of receipt within seven (7) business days of submission.
Step 3: Response/ Determination	Habitat will review your concerns and provide you with an initial resolution, when possible, or response within sixty (60) days.

Your Privacy Matters

We will keep your identity confidential unless we have written authorization from you to release it, or except as necessary to carry out the purposes of federal or state regulations.

We are committed to assuring the privacy of individuals and/or households who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared orally and/or in writing will be managed within ethical and legal considerations. Additionally, we want you to understand how we use the personal information we collect about you. Please ask us for a copy of our full privacy policy.

When you click submit below it may take a few moments. Please only hit the Submit button once.

Thank you for taking the time to complete our Grievance Form.

Habitat for Humanity East Bay/Silicon Valley Home Preservation Department