SD Department of Human Services, Division of Long Term Services and Supports

HCBS@state.sd.us

3800 Highway 34 , Pierre, SD, 57501, US

605-773-3656

DHS Grievance and Feedback Form

The State of South Dakota is committed to helping older adults and individuals with disabilities remain living in the least restrictive environment possible. We appreciate any feedback regarding services you receive that assist you in maintaining independence.

Comments made will not negatively affect the services that you receive.

Where Do You Receive Your Services? (Select all that apply)

Home

Assisted Living

Community Living Home

Adult Day Center

Other

What would you like to report?

I have positive feedback

I have a complaint

Name of the company that provides your services

Name of the company (or companies) that prove your services

Name of the Assisted Living

Name of the Community Living Home

Name of the Adult Day Center where you receive services

Is there a specific staff member your feedback is related to?

Yes

Staff member's name

Date of the incident that resulted in this complaint

If there is more than one date that the incident occurred, describe the timeframe below

Describe your complaint

I would like my name to remain anonymous when LTSS staff contact the provider about my feedback

Yes

Provide your positive feedback here