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COMPLAINT FORM
F
acility
I
nformation
Facility
C
omplainant
I
nformation
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?
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No
You may be contacted by our office for more information.
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Phone
E-mail Address
Relationship to patient, resident, or consumer
A
ffected
P
atient,
R
esident, or
C
onsumer
I
nformation
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
P
reliminary
A
ction
Have you spoken to the administrator, manager, or any staff of the facility about this complaint?
Yes
No
Result
C
omplaint
I
nformation
When did the problem occur?
Time of day?
Unknown
Unknown
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?