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Office of Health Facility
Licensure & Certification

COMPLAINT FORM

Facility Information

Facility

Complainant Information

Do you wish for this complaint to be anonymous? Yes No

If you wish to be anonymous, you will not receive any notification on the status or results of the investigation.

Do you wish for this complaint to be confidential? Yes No

You may be contacted by our office for more information.

Name

Address

Phone

E-mail Address

Relationship to patient, resident, or consumer

Affected Patient, Resident, or Consumer Information

Has patient, resident, or consumer been directly affected by this? Yes No

Name

Age/DOB

Room #/Floor

Diagnosis

Physician Name

Is the patient, resident, or consumer still receiving care or services? Yes No

Preliminary Action

Have you spoken to the administrator, manager, or any staff of the facility about this complaint? Yes No

Result

Complaint Information

When did the problem occur?

Time of day?

Is the problem ongoing? Yes No

Have you filed this complaint with OHFLAC at an earlier date? Yes No

Do you know if this has happened before to the same individual, or to others? Yes No

Are law enforcement agencies involved? Yes No Unknown

Where did the problem occur?

Who are the witnesses, if any?

What Happened?