Title Page
-
Site conducted
-
Date Received
-
Received By
-
Location
-
Select geolocation button if complaint is being received at Store-Level
-
Complaint Number
-
Store Number
-
Store Phone Number
1. Store & Complaint Information
-
Product Brand Name
-
Product Type
-
Product Name
-
Was a retained sample obtained from the complainant?
-
Take a photo of the retained sample
-
Select appropriate reason for complaint. Include brief description and severity in the notes section
- Foodborne Illness
- Foreign Material
- Quality/ Freshness
- Service/ Guest Experience
- Other (Specify in the notes and attach photo)
-
The complaint was received from?
- Complainant
- Store Personnel
-
Name of Store Personnel
-
Phone Number of Store Personnel
2. Complainant Information
-
Select one of the following:
-
First Name and Last Name
-
Phone Number
-
E-mail address
-
Country
-
Province
- Alberta
- British Columbia
- Manitoba
- New Brunswick
- Newfoundland and Labrador
- Northwest Territories
- Nova Scotia
- Nunavut
- Ontario
- Prince Edward Island
- Quebec
- Saskatchewan
- Yukon
-
State
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Viriginia
- Wisconsin
- Wyoming
-
City
-
NOTE: Upon completion of this template please follow up with Corporate QA (Kitty Pat: kpat@bentosushi.com or Rob Trudel: rtrudel@bentosushi.com) to ensure they have received this complaint.
-
Is the report completed (i.e., all questions answered) for submission?
-
Signature
