Public

Complete All Known Information

Please select a Facility Type, which will populate a list of Facilities from which to choose. If you do not know the Facility Type, select Facility Type Not Known and type in the Facility Name.

Facility Type

Facility Name:

Facility Name (as entered by Complainant)

Facility Name (Unlicensed):

Facility Name (Inactive):

Physical Address:

City:

State:

Zip Code:

County:

Facility Telephone:

Facility Email:

Facility Contact Name:

Facility Contact Phone:

Note: Confidentiality of the Complainant is not guaranteed by the Department

DPH may use the contact information provided to contact the Complainant for additional details (NOTE: If you choose to file this complaint anonymously, we will not be able to contact you if we need additional information)

Do you wish to file the complaint anonymously? (If Yes, no further information in this section is needed)

Complainant Name:

Address:

City:

State:

Zip Code:

Email Address:

Contact Phone:

Name:

Age:

Sex:

Male
Female

Room #:

Relationship to you:

Other Relation

Is this person still in the facility?

Yes
No
Don't Know

If no, what was the date of discharge for this person?

If no, where is this person currently located?

Description of Problem ( Please provide as much information as possible including the date, time, how often the concern has occurred, and the location where the concern occurred. Feel free to use exmples. Please list the people involved or any witnesses in the space provided. You may attach additional pages and reports to this form as needed.

Is the situation on-going?

Are there any witnesses?

If Yes, please identify all witnesses:

What are your specific concerns and what do you think should happen regarding this situation?

Did you attempt resolution with Activity?

If so, with Whom?

Date Agency Received:

Received By:

License Number:

Complaint Log Number:

Other Referral

Certification has agreed to investigate?

DPH Form 0284 (05/2014)