'Please contact cfms@justice.wa.gov.au for a copy of the Department's Customer Feedback Policy.'

Your Details:
Title:
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? Yes No
Language/Dialect:
Do you have any special requirements e.g. vision impaired/TTY?
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:
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? No Aboriginal Torres Strait Islander
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? Yes No
Is the person affected by the issue under the age of 18 years? Yes No

The Issue/Feedback:
Feedback Type:
Feedback Regarding:
What part of the organisation does this relate to?
Division:
Directorate:
Branch:
Section:
Have you raised the issue before? Yes No
Are you prepared to be identified to the individuals involved? Yes No
Please provide details about the issue:
When:
Where:
Have you raised the issue before? Yes No
Are you prepared to be identified to the individuals involved? Yes No
Please provide details about the feedback:
When:
Where:
Have you raised this feedback before? Yes No
If applicable are you prepared to be identified to the individuals involved? Yes No
Have you raised this feedback before? Yes No
If applicable 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).