Contact information In this section you will enter your personal contact information. First and last name *Required Do you wish to remain anonymous? *Required YesNo Email address *Required Phone number Mailing address Are you submitting this complaint as a representative of child protective services (CPS), adult protective services (APS), or a law enforcement agency? *Required YesNo Has your agency completed an investigation into this matter? *Required Yes - Supported/substantiatedYes - Unsupported/unsubstantiatedNo - Investigation is ongoingNo - Investigation will not be completed If requested, are you authorized to share a copy of your findings/report? *Required YesNo Facility/provider information In this section you will enter details about the facility where the concern took place. Facility or provider name *Required Facility address Did the complaint take place in a hospital or emergency room? *Required HospitalEmergency roomNeither Were services provided? *Required YesNo If the incident occurred in a hospital emergency room, was the client admitted to the hospital from the emergency room? *Required YesNo Did the patient present to another facility/hospital before or after the complaint hospital? *Required YesNo What was the other facility/hospital and what were the results? *Required If this was a repeat occurrence, was it more common at a particular time of day? *Required YesNo Please explain *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 YesNo Please provide facility names and dates they were involved, if known Have you spoken with anyone at the facility regarding your concerns? *Required YesNo Who did you speak with and when? *Required Have you received a response from the facility? *Required YesNo Has there been any change? *Required YesNo Have you reported your concern to any other agency? *Required YesNo Provide the name of the agency or agencies that you have reported to *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 YesNo Client name(s) *Required Client date(s) of birth Is the client capable of making their own medical decisions and acting as their own responsible party? *Required YesNo What is your legal relationship to the client? *Required Legal guardian (court-appointed)Power of attorney (POA) for healthcare/medical decisionsOther (e.g. next of kin, family spokesperson, relative, etc.)None of the above When was the client first admitted to the facility? Is the client still receiving services through the facility? *Required YesNoUnsure If the client was discharged from the facility, provide the date of discharge Complaint details Provide as much information as possible to describe your concern, including: The dates/times incidents or events in question took place Location(s) of the incident Names/titles of individuals involved Witnesses and their contact information Etc Provide any additional details or information here: You may attach supporting documentation below.