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Please note, if you prefer, you can submit your grievance to the confidential ACOS Client Grievance Voicemail box at 402-257-1122 ext 806. Please be sure to include a complete description of the incident and your contact information.

Clients Name*

Address (if you wish to be contacted)

Email Address*


Phone (if you wish to be contacted)

Parent/Guardian's Name*

Today's Date*

Time of Grievance

Name(s) of All Communities Outreach Staff Involved*

Type of Grievance*

Where did the incident occur?*

Briefly describe the incident or nature of grievance*

What would you like to see done to resolve this incident or grievance?*

What attempts have you already made to resolve this incident or grievance?*

If Returning by Mail, Please send to:

Director Of Quality Improvement

All Communities Outreach Service

112 E. Mission Ave

Bellevue, NE 68005

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