Incident & Grievance Report

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The purpose of the Incident & Grievance process is to provide a vehicle through which a complaint may be brought; a fair and complete investigation undertaken, and appropriate action taken.
The Grievance Committee discusses the circumstances, evaluates the situation, makes recommendations, and initiates change, when appropriate. Involved parties (client, caregiver, or doula) will be notified by the Chair of the Grievance Committee upon receipt and determination of actionability. Upon the completion of this process, you may select whether you wish to be notified and informed of any actions resulting.
To promote fairness, the grievance will be shared with the person, you will have the option to select whether it is the full content, or a summary of your grievance.

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Name of PALS Doula *

May be a certified, certifying, or board member. We can only take actionable steps for active PALS Doulas.

Date of Incident *

YYYY

Where did this situation/event occur? *

What type of grievance are you filing? *

Violation of Ethics Code

Violation of Doula Scope

其他：

Please share any and all information regarding the incident: *

Do you consent to a copy of this grievance being shared with the individual? *

Yes - a word-for-word copy will be provided to the individual

No - a summary of the grievance will be shared, but not a work-for-word copy

Do you wish to be notified of the findings *

Yes

Do you wish to be identified? *

The grievance committee will notify the individual that a grievance has been received and instructed NOT to contact you independently. Named or un-named, If they attempt to contact you, please notify the grievance committee representative at once.

Yes, you may share my name with the individual. I understand that they will have been directed to NOT initiate conversation with me until the completion of this process.

No, I do not want my name shared. By choosing not to be identified the individual will have been encouraged not to contact an unnamed source.

Your name: *

For the grievance committee to pursue action, you must provide your name.

Your email: *

For the grievance committee to pursue action, they must be able to contact you

Your contact #: *

For the grievance committee to pursue action, they must be able to contact you

What is your desired outcome? *

You may select one or more option.

Separate hearings

Recommendations for continuing education

Mediation

Sanctions against the doula (may include probationary status, revocation of certification, revocation or mentorship status, etc)

其他：

If 'Other' above please share:

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