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INVESTIGATION REPORT FORM .
Revised 10/6/94
Part A: Nature of Complaint
• Initiator's Name:
•Address:
• Telephone:
• Owner Name: �0
• Address: LA
• Telephone:
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• Department of Concern
❑ Clerical ❑ Building ❑ Health ❑ Comm Development ❑ Fire
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• Area of Concern:
❑ Process Delay ❑ Personnel ❑ Policy/Fee ❑ Code Violation ❑ Other.
Refer to Director
• Location of Con R
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f.
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•Nature of Conce
Part B: Concern Intake and Referral
Re By: Referred To: Response Date:
sue""' 1 Vr� � •_
Name Date Name Date Date
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Part C: Findings
Referral Forwarded to: ❑N/A
Name Date
Findings:
Part D: Resolution
L r'
Name• Date
Intake Copy-White File Copy-Yellow Referral Copy-Pink
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