Pooled Trust Report Form – Center for Disability Rights

Name of Person Reporting Issue*

First Last

Name of Consumer (If different from person reporting issue)

First Last

Report An Issue*

Please briefly provide a summary of your issue in reference to the Pooled Trust.

Pooled Trust employee(s) you have spoken to regarding issue

Your Email (please provide your email that you use to communicate with the Trust)*

Additional Email (if you have different emails that you used in communication)

Your Phone (please provide your phone number that you use to call the Trust)*

Additional Phone (if used)

Requested Resolution

Please Briefly describe the resolution you are looking for from the Trust.

Ticket # in reference to this issue

(If you were provided one)