File a Grievance : Indiana Recovery Network

Name *

First

Last

Phone No. *

Email *

Relationship to Organization *

Organization Name (Certified RCO against whom Grievance is being filed) *

Organization Primary Contact *

Organization Primary Contact Job Title

Organization Phone Number

Organization Email Address *

Organization Website *

I claim direct, first-person knowledge related to this grievance

Grievant alleges Organization non-compliance with “National Standards of Best Practices for Recovery Community Organizations,” created by Faces and Voices of Recovery listed below or any of the IRN standards for certification. (Please select all that apply) *

Please provide a detailed narrative explaining the nature of the grievance below. *

Supporting Documentation

Click or drag a file to this area to upload.

Acknowledgement

In filing this grievance, I understand that it may be necessary for the Indiana Recovery Network (IRN) to disclose information pursuant to this grievance to the subject RCO as well as to external agencies including DMHA and Recovery Works if applicable. For this reason, the IRN can make no warranty that it will protect the source of this information. However, an attempt is made to withhold disclosure of the source to the extent that is reasonably possible. I authorize unrestricted use of the information filed in this grievance by the Indiana Recovery Network to act as it deems prudent and necessary. Please do not include any personal identifying information or protected health information about any individual.

I certify that the above information is entirely accurate to the best of my knowledge.

Date: *