Ombudsman Complaint Form

ALASKA OMBUDSMAN COMPLAINT FORM
Print this form, fill it out, and mail it to the address at the bottom of the form.
Please answer questions 1-5, then describe your complaint on the second and third pages.
Feel free to add additional pages as necessary.

1	Name ________________________________________________________________________________ Mailing Address ______________________________________________________________________ Daytime Phone Number(______)__________________ Today’s Date____________________
2	Name of agency you are complaining about: ____________________________________________________________________________________ ____________________________________________________________________________________ Where is the agency located? (What city?) ________________________________________________ Is it a state agency?Yes [ ] No [ ] Don’t know [ ] If the agency is not a state agency, the Ombudsman's Office probably cannot help you except to refer you to the right place. The State Ombudsman’s Office only investigates complaints about Alaska state agencies. Have you filed any appeal or grievance with the agency? Yes [ ] No [ ] If you have an appeal or grievance, what was the agency’s answer? Please attach copies of your appeal and the agency’s answer. IT IS IMPORTANT TO TRY TO RESOLVE YOUR PROBLEM WITH THE AGENCY’S HELP BEFORE COMPLAINING TO THE OMBUDSMAN. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Name(s) of the person(s) you spoke or wrote to at the agency about your problem: ______________________________________________________________________________________ ______________________________________________________________________________________ Phone number(s) of the person(s) ______________________________________________________ Has this ever been the subject of a court hearing? Yes [ ] No [ ] If so, what is the court case number? ____________________________________________
3	Have you asked anyone else for help to fix your problem? (An attorney, the Governor’s office, a legislator, for example) Yes [ ] No [ ] May we talk to that person about your complaint? Yes [ ] No [ ] Names and phone numbers of persons you talked to about your problem: ______________________________________________________________________________________ ______________________________________________________________________________________
4	Please give us any other information we need to help us investigate your complaint.(Date of birth, social security number, loan number, case number, license number. If this involves DFYS, include the children's names. If this involves CSED, provide your Member ID Number). _______________________________________________________________________________________ _______________________________________________________________________________________
5	Your name will not be released unless you give your permission. Can we use your name when talking with the agency about your complaint? Yes [ ] No [ ]

Use these lines to briefly state your complaint. Please tell us:

What did the agency do that you do not like or think is wrong?

__________________________________________________________________________________________

What did you want from the agency?

__________________________________________________________________________________________

What do you want the Ombudsman office to do to help you?

__________________________________________________________________________________________

PLEASE SIGN HERE: ___________________________________________________

Please send this form and copies of your agency papers to:

Office of the Ombudsman
Post Office Box 102636
Anchorage, Alaska 99510-2636
FAX (907) 269-5291

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Revised 6/02