Submit a concern

Division of Licensing and Background Checks

This form is for use by clients and members of the public to report concerns. If you are an employee of a licensed program, please fill out a report using your provider portal instead of the form below.
The Office of Licensing investigates complaints regarding unlicensed programs and concerns of rule, statute and law violations in licensed programs. Please submit your concern using the form below or call (801) 890-2007.

    Concern location

    In what type of program did the incident take place? *Required

    May we contact you for further information? *Required

    Contact information

    In this section you will enter your personal contact information.

    Do you wish to remain anonymous? *Required

    Are you submitting this complaint as a representative of child protective services (CPS), adult protective services (APS), or a law enforcement agency? *Required

    Has your agency completed an investigation into this matter? *Required

    If requested, are you authorized to share a copy of your findings/report? *Required

    Facility/provider information

    In this section you will enter details about the facility where the concern took place.

    Did the complaint take place in a hospital or emergency room? *Required

    Were services provided? *Required

    If the incident occurred in a hospital emergency room, was the client admitted to the hospital from the emergency room? *Required

    Did the patient present to another facility/hospital before or after the complaint hospital? *Required

    If this was a repeat occurrence, was it more common at a particular time of day? *Required

    Were there any other involved parties prior to, during, or after the hospital visit (e.g. EMS, fire/rescue, law enforcement, home health agency, SNF, etc.)? *Required

    Have you spoken with anyone at the facility regarding your concerns? *Required

    Have you received a response from the facility? *Required

    Has there been any change? *Required

    Have you reported your concern to any other agency? *Required

    Client information

    In this section you may provide specific details about clients involved in the concern.

    Does this complaint involve a specific client or clients? *Required

    Is the client capable of making their own medical decisions and acting as their own responsible party? *Required

    What is your legal relationship to the client? *Required

    Is the client still receiving services through the facility? *Required

    Complaint details

    Provide as much information as possible to describe your concern, including:

    • Location(s) of the incident

    • Names/titles of individuals involved

    • Witnesses and their contact information

    • Etc.

    Do you know the date/time the incident took place? (approximate date/time is acceptable)