MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION SERVICE DELIVERY GRIEVANCE
IDENTIFYING INFORMATION (TO BE COMPLETED BY GRIEVANT)
NAME	HOME TELEPHONE NUMBER	WORK TELEPHONE NUMBER
HOME ADDRESS	CHILDREN’S SERVICE WORKER	CHILDREN’S SERVICE SUPERVISOR
COUNTY	SSN	FOR OFFICE USE ONLY	DCN	GRIEVANCE #
SECTION A. (TO BE COMPLETED BY GRIEVANT)
GRIEVANCE ISSUE
Briefly describe the situation which caused you to file this grievance. Include date, where it happened, and names of those involved. Use additional sheets if necessary.
DESIRED OUTCOME
State what you would like to have happen with regard to above grievance. Use additional sheets if necessary.
ATTEMPTS TO RESOLVE ISSUE
Describe all actions that have been taken to resolve the issue. Include discussions with worker, their supervisor, and members of the family support team. Use additional sheets if necessary.
GRIEVANT SIGNATURE	DATE
SECTION B. (TO BE COMPLETED BY CIRCUIT MANAGER OR DESIGNEE)
DESCRIBE ACTIONS TAKEN TO RESOLVE GRIEVANCE AT LEVEL ONE. USE ADDITIONAL SHEETS IF NECESSARY.
CIRCUIT MANAGER/SUPERVISOR III SIGNATURE	DATE LEVEL ONE DETERMINATION WAS COMPLETED
SECTION C. (TO BE COMPLETED BY REGIONAL DIRECTOR OR CD ADMINISTRATOR OR HIS/HER DESIGNEE)
DESCRIBE ACTIONS TAKEN TO RESOLVE GRIEVANCE AT LEVEL TWO. USE ADDITIONAL SHEETS IF NECESSARY.
REGIONAL DIRECTOR/CD ADMINISTRATOR SIGNATURE	DATE LEVEL TWO DETERMINATION WAS COMPLETED
SECTION D. (TO BE COMPLETED BY DIVISION DIRECTOR OR HIS/HER DESIGNEE)
DESCRIBE ACTIONS TAKEN TO RESOLVE GRIEVANCE AT LEVEL THREE. USE ADDITIONAL SHEETS IF NECESSARY.
DIVISION DIRECTOR SIGNATURE	DATE LEVEL THREE DETERMINATION WAS COMPLETED
DESCRIPTION OF THE SERVICE DELIVERY GRIEVANCE PROCESS
The Children’s Division (CD) is committed to providing the children and families of Missouri with the best possible programs and services in the most professional manner. You have the right to file a grievance if you are dissatisfied with the services you have received or if you feel you are not being treated in a fair and respectful way. No CD staff member will take action against you if you file a grievance. What is a grievance? A grievance is a complaint in which the person believes there is just cause for protest or disagreement. A grievance may be any disagreement or complaint a youth or family member has with an employee or a contractor of the Children’s Division. A grievance may be related to a variety of service provision issues. Who may file a grievance? Any adult family member currently receiving services or has had services terminated within the past 30 days. Youth 12 years of age or older. Any child younger than 12 years of age with the assistance of a parent, guardian, resource provider, or Guardian ad Litem. Any resource provider, (except resource providers who work with contracted agencies to provide care.) What is not grievable through this process? Any complaint of discrimination based upon, race, color, national origin, age, sex, disability, religious or political beliefs. Forward these complaints to: Department of Social Services Office for Civil Rights, P.O. Box 1527 Jefferson City, MO 65102, Phone: 1-800-776-8014, Text/Voice: 1-800-735-2466/1-800-735-2966 Any complaint involving or alleging criminal activities of employees. The Regional Director, or his/her designee, shall refer these complaints immediately to the Division Director’s Office for review and necessary action. Any dispute with the outcome of a Child Abuse/Neglect investigation. These complaints shall proceed through the established CA/N Appeal process. Any court ruling or current statute. Guardian ad Litem (GAL), Court Appointed Special Advocate (CASA), or judge appointments. Complaints about these appointments must be addressed through the court of jurisdiction. Any foster/adoptive licensing revocations or denials. Any complaint by an alternative care provider about a case management decision regarding a child in their care. Subsidy grievances, for those persons receiving adoption or guardianship, shall proceed through normal Children’s Division supervisory channels. The grievance process is designed to resolve complaints and disagreements at the most local level possible. Before filing a formal grievance, be sure that you have tried to resolve the complaint through discussions with your Children’s Service Worker, their Supervisor, and other members of your Family Support Team. If you are still not satisfied, then you may file a formal grievance by filling out Section A of the Service Delivery Grievance Form and returning it to the Circuit Manager in the county in which you received services.
STEPS IN THE SERVICE DELIVERY GRIEVANCE PROCESS
Level 1: Fill out Section A of the Service Delivery Grievance Form Turn completed form into your county office Work with Circuit Manager or his/her designee to resolve problem Within 15 working days you will receive a response, on the same form you turned in, from the Circuit Manager If resolved IF NOT RESOLVED Level 2: Within 15 days of receiving response from Level 1, turn in a copy of the Service Delivery Grievance Form received from Level 1 to the Regional Director or his/her designee Work with the Regional Director or his/her designee to resolve the problem Within 15 working days you will receive a response from the Regional Director or his/her designee If resolved IF NOT RESOLVED LEVEL 3: (THIS IS THE FINAL LEVEL) Within 15 days of receiving response from Level 2, turn in a copy of the Service Delivery Grievance Form received from Level 2 to the Division Director’s office Work with the Division Director or his/her designee to resolve problem Within 15 working days you will receive a response from the Division Director or his/her designee You may ask your Children’s Service Worker, a friend, or family member to help you fill out the Service Delivery Grievance Form. During the process you may talk with CD staff in person or by phone. It is not required that you come to the CD office in person.