Feedback Form

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Date of feedback *

Is this a... *

	Complaint		Compliment
	Complaint		Compliment

Please select the Shire you live in: *

Please select the program or service area that your feedback concerns. *

Please provide a description of the compliment, complaint or feedback.

What resolution (if any) are you hoping for?

Would you like us to contact you to discuss the complaint and what we can do to follow up?

Yes - please provide your contact details below No - I do not wish to be contacted (select 'Done' at the bottom of the screen) No - I am providing a compliment (select 'Done' at the bottom of the screen)

Your Name

Preferred Pronouns (optional)

Your email address (if this is your preferred method of contact):

Your phone number (if this is your preferred method of contact):

Your Organisation (if applicable)

Name of person completing this form (if different from above, e.g. an Omnia Staff member)

Done

Zonka Feedback

Thank you for your feedback. Your comments have been shared with the appropriate team. If you requested a response, someone will be in touch. We appreciate you taking the time to provide your feedback.

Zonka Feedback