Facility Complaint Form

Note: Because we may need specific information to properly handle your complaint, we cannot accept complaints by e-mail from people who prefer not to give us their contact information. However, please note that when investigating complaints, the department does not reveal the indentity of the complainant. If you still wish to remain anonymous, please file your complaint by calling 1-800-792-9770.
Facility Information
Facility Name: (Required)
Street:(Required)
City:(Required) State:    Zip:
Type of Facility:(Required)

Contact Information from person filing the complaint
Last Name: First Name:
Street Address:
City: State:  Zip:
Email:
Phone Numbers:(999-999-9999)
Home: Work:
Cell:

Patient Information
Your Relationship to the Patient:
Name of Person Referred to in this complaint
(patient/resident name or self):
Room Number:
Patient's Date of Birth: (dd/mm/yyyy)

Incident Information
Type of Incident:(Required)
Describe the event, be specific, include date and time, staff/others involved, action(if any, taken by the facility):(maximum 500 characters)(Required)
Was this reported to the facility staff?(Required)
If yes, to whom did you report the event?
Was this reported to any other agency?(Required)
If yes, what agency? i.e. ombudsman, police