Complaints, Incidents, and Comments

Complaints, Incidents, and Comments

Person Completing Form

Please include your first and last name.

Event Date

This field should capture the date of the specific event being documented. This could include incidents, complaints, comments, or any notable occurrence relevant to the record.

Event Type

Please select the type of event that best describes your submission. We aim to categorize events for accurate reporting and follow-up. If our options do not adequately capture your event, you may free-type in this field or leave it blank for our staff to review and determine the most appropriate categorization.

Select or enter value

Explanation of Event

This field should provide a detailed account of the complaint, comment, or incident. It’s important to include factual information, such as specific events, dates, and timelines, to assist in the follow-up process. A clear and comprehensive explanation will facilitate a better understanding of the situation, allowing for effective investigation and resolution. Please avoid subjective language and focus on presenting the facts to ensure accuracy and clarity in the documentation.

Desired Outcome/Resolution

Please describe how you believe this issue, incident, or complaint should be resolved. What outcome are you hoping to achieve by submitting this information?

Persons Involved

This section should list all individuals relevant to the event being documented. Include their full names, roles, and any pertinent contact information, if applicable. This may consist of witnesses, complainants, or any other parties associated with the incident. Providing comprehensive details will help facilitate follow-up actions and ensure accurate records.

Relationship to Patient

This field should specify the relationship of the person involved to the patient. If the submission does not pertain to a specific patient, please indicate “N/A” (Not Applicable) to ensure clarity in the documentation. This will help maintain accurate records and facilitate any necessary follow-up actions.

I am the patient

Date of Birth (for Patient Records)

This field is required to facilitate a secondary identification check when accessing patient health information related to the submitted complaint, comment, or incident. Providing the correct date of birth ensures that we can accurately investigate and follow up on the submission while maintaining patient confidentiality and security.

Follow-Up Request*

Would you like to receive follow-up communication regarding this submission? If yes, please provide accurate contact information in the fields below. It’s important to double-check your phone number and mailing address to ensure we can reach you effectively.

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Mailing Address (Patient or Person Completing the Form)

This field is typically only used when physical documents need to be sent to the recipient as part of the resolution process. Please provide the complete mailing address, including street, city, state, and ZIP code, if applicable. Otherwise, this information may be left blank.

Primary Phone Number

Please provide the best phone number for us to reach you regarding follow-up on this submission. This number will be used to discuss any questions or clarifications related to the complaint, comment, or incident, ensuring effective communication throughout the resolution process.

Alternate Phone Number

If available, please provide a secondary phone number where you can be reached. This number will serve as an additional contact method for follow-up regarding your submission, ensuring we can communicate effectively even if we are unable to reach you at your primary number.

Attachment Upload

Please attach any relevant documents.

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