Home How Do I? File a complaint File a complaint Edit Form Complaint Intake Form Section 1: Complainant Information First Name? Last Name? Address? Phone Number? Alternate Phone Number? Person Completing this form? ANONYMOUS? I would like to remain anonymous Section 2: Initial Details 1. Nature of the complaint*? 2. Did this involve a resident?*? Yes No 3. Resident's Name? Resident's Room Number? Resident's Unit? 4. Has this been reported to the facility previously?*? Yes No If you answered YES, please complete the next 4 fields To whom was this reported?? Date reported to facility? Time reported to facility? Response to complainant? Has complainant tried resolving this issue?*? Yes No If you answered YES to the previous question, please describe how you tried to resolve this issue? Has complainant contact other agencies? (i.e Ombudsman)? Yes No 6. Does the complainant have firsthand knowledge of the alleged violation?* Yes No If you answered YES to the above question, please provide details? Section 3: 1. Date allegation occurred*? Time allegation occured*? 2. Who was involved? Names/Titles:*? 3. Is this an isolated incident or ongoing?*? 4. What is the reason you believe this occured?? 5. What needs to happen for this issue to be resolved?*? Additional Notes? You have a right to request a written decision regarding your complaint. Please let us know what type of correspondence you would like to recieve.* Written correspondence NO correspondence (anonymous complaint)
