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Complaint Form
Facility/Provider Information Section
Facility/Provider Type
---Select Facility Type---
Abortion Clinics
Ambulatory Surgical Facilities
Birthing Centers
Body Piercing Facilities
Community Residential Care Facilities
Crisis Stabilization Unit
Day Care Facilities for Adults
Facilities for Chemically Dependent or Addicted Persons (Inpatient)
Facilities for Chemically Dependent or Addicted Persons (Outpatient)
Hearing Aid Specialists (Licensed)
Hearing Aid Specialists (Temporary Permit)
Home Health Agencies
Hospice (Inpatient Facilities)
Hospice (Outpatient Programs)
Hospitals and Institutional General Infirmaries
Inhome Care Providers
Intermediate Care Facilities for Persons with Intellectual Disability (15 Beds or Less)
Intermediate Care Facilities for Persons with Intellectual Disability (16 Beds or More)
Midwives (Apprentice)
Midwives (Licensed)
Nursing Homes
Renal Dialysis Facilities
Residential Treatment Facilities for Children & Adolescents
Tattoo Facilities
UnLicensed Health Facilities
Facility Type Not Known
Facility/Provider Name
---Select Facility Type First---
Facility/Provider Name (Unlicensed)
Facility/Provider Name (Unknown)
Physical Address
Apt, Suite, etc (optional)
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County
-- Select County --
Abbeville
Aiken
Allendale
Anderson
Bamberg
Barnwell
Beaufort
Berkeley
Calhoun
Charleston
Cherokee
Chester
Chesterfield
Clarendon
Colleton
Darlington
Dillon
Dorchester
Edgefield
Fairfield
Florence
Georgetown
Greenville
Greenwood
Hampton
Horry
Jasper
Kershaw
Lancaster
Laurens
Lee
Lexington
Marion
Marlboro
McCormick
Newberry
Oconee
Orangeburg
Pickens
Richland
Saluda
Spartanburg
Sumter
Union
Williamsburg
York
Out of State
Facility/Provider Phone
Facility/Provider Email
Facility/Provider Contact Name
Facility/Provider Contact Phone
Complainant Information Section
Confidentiality of the Complainant is not guaranteed by the Department
DPH may use the contact information provided to contact the Complainant for additional details
Do you wish to file anonymously?
Yes
No
Complainant Name
Physical Address
Apt, Suite, etc (optional)
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Email
Phone
Resident / Client / Patient Information Section
Name
Date of Birth
Sex
Male
Female
Relationship to you
-- Choose One --
Resident (Self)
Family Member - Child/Parent/Spouse
Friend
Law Enforcement Agency
Legal Representative/Guardian/Power of Attorney
Media
Staff Employee - Present/Former
Ombudsman
Quality Improvement Organization
Other - Please Explain
Relationship (Other) (optional)
Is this person still in the facility?
Yes
No
Not Applicable
Room Number
What was the date of discharge for this person? (optional)
Where is this person currently located? (optional)
Description of problem
Is the situation on-going?
Yes
No
Are there any witnesses?
Yes
No
Please identify all witnesses (optional)
Did you attempt to resolve the issue with the facility or provider?
Yes
No
With whom did you attempt resolution? (optional)
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