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   Norfolk Department of Human Services 

   Customer Complaint Form

5. Directions

   NDHS is committed to excellent customer service and will make every effort to resolve your concern in a professional and timely manner. If you have raised your concern with the worker and supervisor informally and are still not satisfied with the response, a formal written complaint may be filed. Someone will contact you to discuss your concerns as soon as possible, but no later than 1 business day. If you need assistance filling out this form, please contact the Customer Service Liaison at 757-439-1035. Thank you.

7. Customer Information
9. Date
   Date
10. Phone*
12. Full Name*
13. Email*
15. Address 1
17. Address 2
19. City
20. State
21. Zip
23. Program Area
25.  *

    1. Adoptions
    2. APS
    3. CARES T.E.A.M
    4. CPS
    5. Day Care
    6. Energy Assistance

    1. Family Support
    2. Family Team Meetings
    3. Finance / Payments
    4. Foster Care
    5. Home-Based Childcare Network

    1. Medicaid
    2. NJDC
    3. SNAP
    4. TANF
    5. VIEW
27. Location
29. Where does the employee work?

    1. Norfolk Juvenile Detention Center (NJDC)
    2. Human Services Building - 741 Monticello Avenue

    1. Teleworker
31. Employee Name
32. Employee Phone #
34. Describe Concern
36. Please give a brief description of your complaint.*
38. Who completed this form?

    1. Customer
    2. Customer Service Liaison
    3. Other
39. If other checked please explain.
41. Desired Resolution
43. What action by the Department of Human Services would resolve this matter to your satisfaction?*
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field