Healthicity Audit and Compliance Solutions

Seneca Nation Health System

Comment/Complaint/Grievance Response System (CCGRS) Form

Please fill out this form if you use SNHS services and you wish to make your comment/complaint/grievance known to the Health System Administration. Paper copies of this form are available at all SNHS facilities and can be submitted to any staff member.

Date observed or first noticed

Time of Incident

Location

Additional Location Details (room, area, offsite location, etc.)

Who or what was affected?

Names of persons this matter involves:

Names of any witnesses present:

Please select the department involved in this matter:

Description of event(s) or concerns

Please provide any additional comments or recommendations to address/resolve your issue.

Are you willing to discuss this issue with us further? Yes (Compliance or HR Team May Contact Me)No (Remain Anonymous - Do Not Contact Me)

I understand that I waive the right to receive follow-up and/or appeal an unsatisfactory response if this form is filled out anonymously or without current/accurate contact information.

Do you want to save a copy of this report to your device? YesNo

If you have requested a follow-up response and feel the initial response provided is unsatisfactory, you may appeal to the CEO to review the matter within ten (10) business days of receiving the initial repsonse.