Health Care Facility Complaint Form
Complaint Intake Form
1. What is the name and address or city of the facility or agency you are filing a complaint about?
Name:
Address, City, State & ZIP:
2. What is your name, mailing address, telephone number, and email address?
Last : First: Middle:
Address, City, State & ZIP:
Daytime Telephone: Email:
What is your employee status with this
facility/agency? (This information to be used for
internal administrative purposes only.)
3. What is the name, date of birth and gender of the affected patient/client? (If more than one patient/client list all
on separate attachment.)
Last : First: Middle:
Date of Birth: Male Female
4. What is your relationship to the patient/client?
5. If the patient was in a facility, in what department, or on what unit or floor did the incident(s) or
problem(s) occur?
6. What date was the patient/client admitted to the facility/agency?
7. Is the patient/client still in the facility or still
receiving agency services? Yes No
8. What date was the patient/client discharged from facility/agency services?
9. What were the date(s) and time(s) that the incident(s) or problem(s) occurred?
10. Please describe what happened in detail. (If additional space is needed please attach separate piece
of paper.)
Version 3.0 (Aug. 2011)
11. To summarize, what do you believe the facility/agency did wrong?
12. Does anyone else have first hand knowledge of the incident(s) or the problem(s)? Such as
facility/agency staff, volunteers, family members, other patients or clients, visitors? Please list the names,
relationship/title and if you know it, telephone contact information for those witnesses/individuals?
13. Have you filed a complaint with anyone at the facility/agency? If so, with whom, when, and have you
received a response?
What was their response?
14. Have you reported this to, or filed a complaint or action with, any other agency or organization? Such
as law enforcement, ________ Services, professional licensing boards? If so, which agencies,
when, and what were the actions or findings?
15. Was a specific staff member involved? YesNo
If yes, please provide their name/position, if you know it.
16. Was the incident reported to staff? YesNo
If yes, to whom was it reported?
17. Have you reported this to other Agencies?
1. What happens after I submit a complaint?
2. Is my personal and complaint information kept confidential?
3. If an investigation is completed, how do I request a copy?