1. Name

2. Address



Postcode:

3. Contact telephone numbers

4a. Fax number

4b. E-mail address

5. Are you referring the complaint on behalf of someone else?
If the answer is "no" please go to question 10

6. Name

7. Address



Postcode:

8. Explain why you are referring the complaint

9. Are you referring the complaint with the agreement of the above person/organisation?

10. Please explain your complaint/s as clearly and precisely as possible.

11. Have you received a final written response to your complaint from the Youth Justice Agency?

12. When did you receive the response from the Youth Justice Agency?

13. Has your complaint been referred to the Office of the N.I. Ombudsman? If so please provide details

14. How would you like the Youth Justice Agency to put the matter right for you?

15. Please forward all relevant documents to the ICR. Please list below the documents you are sending (Please post all documents to the ICR office)

Please read the following information and then check the box to confirm that you want to refer your complaint to the ICR

• You will need to handle personal details about me, which could include sensitive information in order to deal with my complaint effectively.
• . You will need to exchange information about my complaint with the Youth Justice Agency (for example to find out important facts about my case).
• You handle complaints in a different way from the courts, not requiring people to attend hearings in person, but resolving disputes by correspondence.
• You may publish examples of where things can go wrong, based on real cases, but you will always respect my privacy and keep my personal information confidential.