Customer Complaint Form
When you have filled in this form please press the submit button. An automatically generate reference number will be displayed (Please make a note for future reference) An e-mail receipt will be sent to you quoting the reference number if you requested response by e-mail.
1.
Title
First Names
If Other, please state
Surname
2.
Your Address
Do you require feedback

If Yes, please select one of the following:
Town
Email
County
Phone Number
Postcode
3
We are committed to offering equal opportunities to our customers. To ensure the effectiveness of this policy anyone submitting a customer comment form is asked to provide the information below. This will be treated in the strictest confidence and will be used only to monitor the effectiveness of the Equal Opportunities Policy. (This information will not be passed on to whoever is asked to respond to your complaint). Please indicate how you would describe your ethnic origin. The categories listed below relate to descent, not country of birth/nationality or citizenship.
White
White British
White Irish
White Other

Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian Background

Chinese
Chinese		Black
Black British
Black Caribbean
Black African
Other Black background

Mixed Race
White & Black Caribbean
White & Black African
White & Asian
Other mixed background

Other Group
Gypsy / Traveller

Other (please state)
Are you Female or Male?
Female
Male

Do you have a long term limiting illness or disability?
Yes No		What age range are you?
25 or under
26-50
51-65
66-75
Over 75
In your opinion is Kennet District Council providing services to meet the needs of ethnic minorities in our communities?
 Yes No Not Sure
4
What do you think the Council did wrong or did not do?


5
How have you been affected by the Council's actions and what injustice have you suffered?
6
What do you think the Council should do to put things right?
7
On what date did you first find out about the matter you are complaining about?

Please enter date in dd/mm/yyyy format
8
Have you already complained to the Council? Yes No
If so: (a) what is the name and job title (if known) of the person you complained to?
(b) on what date did you complain?
(c) was your complaint in writing? Yes No
(d) have you received a written reply? Yes No
9
Have you complained in writing to a councillor? Yes No
If so:
(a) what is the name of the councillor you wrote to?
(b) on what date did you write?
10.
If there is anything which makes it difficult for you to use our service, for example, if English is not your first language or you have a disability, please use the space below to tell us how we might help you.
If you have any documents to support your complaint, for example letters from the Council, please send these by post clearly quoting the reference number which will be set out in the e-mail you will receive following submission, or upload these here



Please note that for the purposes of the Data Protection Act 1998 the information which you give may be used for any of the Council's statutory purposes particularly for the improvement of its services to the public.