Weatherization Manual Policies and Procedures Supporting Documents for United States Department of Energy (doe) United States Department of Health and Human Services (hhs) Bonneville Power Administration

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Client Complaint Form

Client Information



Social Security #

Telephone #

First Name


Last Name

Service Address



Zip Code

Nature of Complaint:

Denial of service


Deferral policy

Application not handled in a timely manner

Dissatisfaction with work
Details of Complaint:

Action Taken:

Client directed to appropriate program staff

Client received copy of agency dispute resolution process and Service Review Request

Client sent copy of agency dispute resolution process and Service Review Request


Details of Action Taken:

Program staff contacted: Yes Date contacted:

Name of program staff contacted:
Copy of Client Complaint Form in client’s file Complaint noted in program database

Complaint Received By:

Date to Client:


Service Review Request

Complete this form with the information requested. A written account is required for review to proceed.




Home or Message Phone: Work Phone:

Describe the circumstances for which you are requesting a service review. What happened? When did it happen? Where did it happen? Who is involved or who may have knowledge of the situation? Attach a separate page if needed.

When are you available to meet to discuss this matter?

Date 1: Morning/Afternoon (circle one or both)

Date 2: Morning/Afternoon (circle one or both)

I certify that the above statements are true and accurate to the best of my knowledge.

Your Signature: Date:

Give this completed form to any agency staff member or mail in envelope provided. It will be promptly forwarded to the supervisor/director of the program/division involved. You will be contacted within 10 working days of the date received to confirm a meeting time.

Office Use:

Received by Date Received

Office Use:

Received by: Title: Date:

Reviewed by: Title: Date:

Participant contacted, meeting scheduled: Date:

In-office meeting Telephone meeting In-home meeting

Notes from meeting:

Name/Position: Date:


Name/Position: Date:




Phone Number:


Project Number:

As a result of reviewing your concerns with you and the details of your file, the following conclusion has been reached:

We will keep a copy of this information in our files for the next 18 months. If you are not satisfied with the above conclusion and would like further review of your complaint, please indicate in the space provided at the bottom of this letter and return. Thank you for participating in this process.


Name Title Date

Name: Telephone Number:

Address: Best time to call:
I request further review of this situation. My reasons and comments are in the space below. (Attach a separate sheet if needed.)

Your Signature: Date:

Dispute Resolution Fact Sheet

Arbitration is the submission of a dispute to one or more impartial persons for a final and binding decision. Through contractual provisions, the parties may control the range of issues to be resolved, the scope of relief to be awarded, and many procedural aspects of the process.


Under Chapter 7.04 RCW, all arbitrations are final and binding unless there is arbitrator misconduct or the arbitrator obviously disregarded the law.

Mediation is a process whereby a neutral person – the mediator – assists the parties in reaching a mutually acceptable resolution to their dispute. The mediator does not have the authority to make a binding decision, unlike arbitration, where the arbitrator renders a decision that is final and binding.

Appropriate Uses Of Mediation

Any civil dispute between two or more individuals or groups is appropriate for mediation. All parties to the dispute must be able to comprehend and be willing to use the third party role of mediation. Thus individuals with impaired mental or emotional functioning often are unable to enter into productive negotiating. Also, individuals who have been part of a violent pattern of victimization usually are not able to negotiate in their best interests if they are the victims or stop intimidating behaviors if they are the persecutors. Such situations usually are not amenable to mediation.

What are Some Advantages of Mediation?

  • Parties are directly engaged in negotiating the settlement.

  • The mediator, as a neutral third party, can view the dispute objectively and can assist the parties in exploring alternatives that they might not have considered on their own.

  • As mediation can be scheduled at an early stage in the dispute, a settlement can be reached much more quickly than with litigation.

  • Parties generally save money through reduced legal costs and less staff time.

  • Mediators have been carefully chosen for their knowledge and experience.

  • Parties enhance the likelihood of continuing their business relationship.

  • Creative solutions or accommodations to special needs of the parties can become a part of the settlement.

  • Information disclosed during mediation may not be divulged as evidence in any arbitral, judicial, or other proceeding.

How Does Mediation Differ From Arbitration?

Arbitration is less formal than litigation, and mediation is even less formal than arbitration. Unlike an arbitrator, a mediator does not have the power to render a binding decision. A mediator does not hold evidentiary hearings as would an arbitrator but instead conducts informal joint and separate meetings with the parties to understand the issues, facts, and positions of the parties. In contrast, arbitrators hear testimony and receive evidence in a joint hearing, on which they render a final and binding decision known as an award. In joint sessions with each side, a mediator tries to obtain a candid discussion of the issues and priorities of each party. Gaining certain knowledge or facts from these meetings, a mediator can selectively use the information derived from each side to:

  • Reduce hostility between parties and help them engage in meaningful dialogue on the issues at hand.

  • Open discussions into areas not previously considered or inadequately developed.

  • Communicate positions or proposals in understandable or more palatable terms.

  • Probe and uncover additional facts and the real interests of parties.

  • Help each party to better understand the other parties’ views and evaluations of a particular issue without violating confidences.

  • Narrow the issues and each party’s positions, and deflate extreme demands.

  • Gauge the receptiveness for a proposal or suggestion.

  • Explore alternatives and search for solutions.

  • Identify what is important and what is expendable.

  • Prevent regression or raising of surprise issues.

  • Structure a settlement to resolve current problems and future parties’ needs.

Dispute Resolution Resources


American Arbitration Association (AAA)

Regional Office

1 Convention Place

701 Pike Street, Suite 950

Seattle, WA 98101-4111

(206) 622-6435 

Fax: (206) 343-5679


Resolution Washington: An Association of Dispute Resolution Centers

Dispute Resolution Center Listings

If a dispute resolution center (DRC) is not available in your immediate area, contact the nearest center to discuss your agency’s options.

Bellevue Neighborhood Mediation Program

11511 Main Street, P.O. Box 90012

Bellevue, WA 98009-9012

(425) 452-4091

Web site:
Benton Franklin Dispute Resolution Center

5219 W. Clearwater, Suite 11

Kennewick, WA 99336

(509) 783-3325

Fax: (509) 783-3449


Web site:
Community Mediation Services

610 Esther St., P.O. Box 1995

Vancouver, WA 98668-1995

(360) 619-1140

Fax: (360) 696-8009


Web site:
Dispute Resolution Center of Kitsap County

9004 Washington Ave. NW

Silverdale, WA 98383

(800) 377-6583 or (360) 698-0968

Web site:
Dispute Resolution Center of Lewis County

57 W. Main St., #185

Chehalis, WA 98532

(360) 748-0492

Fax: (360) 748-7717


DRC of Island and Snohomish Counties

Mailing: P.O. Box 839

Street: 2801 Lombard Avenue

Everett, WA 90206

(800) 280-4770 or (425) 339-1335

Fax: (425) 259-2110


Web site:

Dispute Resolution Center of Thurston County

PO Box 6184

Olympia, WA 98507

(360) 956-1155

Fax: (360) 357-5168


Web site:
Dispute Resolution Center of Yakima and Kittitas Counties

1106 B. West Lincoln Ave.

Yakima, WA 98902

(509) 453-8949 or 1 (800) 853-8949

Fax: (509) 453-0910


Web site:


Fulcrum Institute Dispute Resolution Center

905 W. Riverside, Suite 304

Spokane, WA 99201

(509) 838-2799

Fax: Same as telephone
King County Dispute Resolution Center

P.O. Box 21148

Seattle, WA 98111

(888) 803-4696 or (206) 443-9603

Fax: (206) 443-9737

Web site:

Mediation and Settlement Center

138 1st Street South, Suite 6

Montesano, WA 98563

(360) 249-1925

Fax: (360) 249-1926


Neutral Ground - Walla Walla

P.O. Box 1222

Walla Walla, WA 99362

(509) 522-0399

NW Conflict Management Center

Community Building

35 W. Main, Suite No. 230

Spokane, WA 99202

(509) 456-0103

Fax: (509) 462-0525

Okanogan County Dispute Resolution Center

17 S. Ash St. – P.O. Box 3567

Omak, WA 98841

(509) 826-1776


Peninsula Dispute Resolution Center

P.O. Box 1035

Port Angeles, WA 98362

(360) 452-8024


Web site:

Pierce County Dispute Resolution Center

917 Pacific Avenue, Suite 206

Tacoma, WA 98402

(253) 572-3657

Fax: (253) 572-3579


Web site:
Skagit County Mediation Services

601 South Second St.

Mount Vernon, WA 98273

(360) 336-9494

Web site:
Whatcom Dispute Resolution Center

13 Prospect St.

Bellingham, WA 98225

(360) 676-0122

Web site:

Training Opportunities

Many DRCs offer mediation training throughout the year. Contact individual DRCs for training schedules.

Link to Active Form: Exhibit 5.1A(1), PL CALC-Site built

Priority List Calculation Sheet – Site Built

(PL CALC-Site Built)

Link to Active Form: Exhibit 5.1A(2), PL CALC-Mobile Home

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