'Please contact cfms@justice.wa.gov.au for a copy of the Department's Customer Feedback Policy.'
Your Details:
Title:
Mr
Mrs
Ms
Miss
Master
Dr
Professor
Given Names:
Last Name:
Organisation:
(if applicable)
Address:
Suburb:
State:
Postcode:
Country:
Email:
Phone No:
Fax No:
Mob/Work No:
Do you require an interpreter?
Do you require an interpreter?
Yes:
No:
Language/Dialect:
Do you have any special requirements e.g. vision impaired/TTY?:
Are you the person affected by the issue?
Are you the person affected by the issue?
Yes:
No:
Other Details:
(If you are representing someone we may need to confirm your authority to act for that person)
Title:
Mr
Mrs
Ms
Miss
Master
Dr
Professor
Given Names:
Last Name:
Address:
Suburb:
State:
Postcode:
Country:
Phone No:
Please indicate why you are representing this person:
Demographics:
Is the person affected by the issue of Aboriginal or Torres Strait Islander origin?
Is the person affected by the issue of Aboriginal or Torres Strait Islander origin?
No
Aboriginal
Torres Strait Islander
Does the person affected by the issue come from a culturally and linguistically diverse background?
Does the person affected by the issue come from a culturally and linguistically diverse background?
Yes:
No:
If yes, please specify:
Is this a disability issue?
Is this a disability issue?
Yes:
No:
Is the person affected by the issue under the age of 18 years?
Is the person affected by the issue under the age of 18 years?
Yes:
No:
The Issue/Feedback:
Feedback Type:
Complaint
Compliment
Suggestion
Feedback Regarding:
Access to Services
Communication
Contractors
Costs
Decision Making
Delivery of Services
Disability access
Facilities
Fraud/Criminal Activity/Breach of PSS
Legal
Legislation
Judicial
Policy
Privacy
Processes & Procedures
Products (eg certificates, website, brochures)
Staff
Other
What part of the organisation does this relate to?
Division:
Directorate:
Branch:
Section:
What happened and who was involved? (maximum 400 words):
What solution is sought? (maximum 400 words):
Have you raised the issue before?
Have you raised the issue before?
Yes:
No:
Are you prepared to be identified to the individuals involved?
Are you prepared to be identified to the individuals involved?
Yes:
No:
Are you a victim of crime?
Are you a victim of crime?
Yes:
No:
Please provide details:
When:
Where:
What happened and who was involved? (maximum 400 words):
What would your preferred resolution be? (maximum 400 words):
Have you raised the issue before?
Have you raised the issue before?
Yes:
No:
Are you prepared to be identified to the individuals involved?
Are you prepared to be identified to the individuals involved?
Yes:
No:
Are you a victim of crime?
Are you a victim of crime?
Yes:
No:
Please provide details:
When:
Where:
What happened and who was involved? (maximum 400 words):
Have you raised the issue before?
Have you raised the issue before?
Yes:
No:
Are you prepared to be identified to the individuals involved?
Are you prepared to be identified to the individuals involved?
Yes:
No:
Please provide details (maximum 400 words):
Have you raised the issue before?
Have you raised the issue before?
Yes:
No:
Are you prepared to be identified to the individuals involved?
Are you prepared to be identified to the individuals involved?
Yes:
No:
Should you wish to change any information after it has been submitted you should contact the Feedback Manager on 9264 6270 and quote the allocated reference number (this is provided after you have selected the "Submit" button).
