Complaint Form printable pdf download

Office Use ONLY

Date Complaint

Received:

Complaint no.:

COMPLAINT FORM

(Use date-stamp)

State of Arizona Board of Examiners of

Nursing Care Institution Administrators & Assisted Living Facility Managers

1400 West Washington Avenue, Suite B-8● Phoenix, AZ. 85007

Phone 602-.364-.2273● Fax 602-542-8316

State Law requires we have to disclose your name unless we can show that disclosure will result in substantial harm to you,

someone else or the public per A.R.S. §41-1010. If you have reason to believe that substantial harm will result in disclosure of

your name please provide copies of restraining orders or other documentation.

The investigation of your complaint may take several months to complete. The investigator may contact you for additional

information or clarification. When the investigation is completed you will be notified of the date and time the Board will review

your complaint. After the Board reviews your complaint, you will be notified in writing of their decision. Any exhibits or

documents you include will become a part of our permanent investigative file and cannot be returned

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COMPLAINANT:

Name of Reporting Party: _________________________________________________________________________

Address: ______________________________________________________________________________________

Telephone numbers:

Home: ___________________________ Cellular:________________________________

Work: _____________________ Message: _____________________ E-mail: _____________________________

Resident’s full name: ____________________________________________________________________________

Resident’s Age: ________________ Reporting Party’s Relationship to the Resident:_________________________

Have you previously contacted the administrator or manager about your complaint? Yes: ____ No: ____

Have you filed a complaint with any other agency regarding these same allegations? Yes: ____ No: ____

If Yes, please list the names of those agencies and if known a case number or contact name:_____________________

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COMPLAINT AGAINST:

Administrator or Managers full name: ______________________________________________________________

Facility Name: _________________________________________________________________________________

Facility Address: ________________________________________________________________________________

Facility telephone number: ________________________________________________________________________

Please be as detailed as possible when writing your complaint, listing names, events, dates, times, etc. If your

complaint has more then one allegation, please write each one separately. Also, provide any documentation

that substantiates your complaint. You may attach as many additional pages as needed.

Signed: ________________________________________

Date: ____________________________

Complaint Form