Form Hea1685 - Complaint Form - Ohio Department Of Health

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PROVIDER AND CONSUMER SERVICES UNIT
DIVISION OF QUALITY ASSURANCE
OHIO DEPARTMENT OF HEALTH
COMPLAINT FORM
You may file this complaint ANONYMOUSLY, by NOT providing us your name and address. Skip to
Section II if you wish to remain anonymous. If you remain anonymous, ODH will not be able to contact you
to obtain additional information or notify you of the results of the complaint investigation.
Section I Complainant Information – Complete only if you wish to receive our acknowledgement and
*Red outlined fields are mandatory
notification letters with the results of the complaint investigation
Complainant Name:
Street Address:
City:
State:
Zip:
Primary Telephone:
Secondary Telephone:
(
)
(
)
NOTE: All person-identifiable information is confidential.
Section II Facility Information
*Facility Name:
*Facility Type:
*Address:
City:
State:
Zip
Telephone:
Section III Resident(s)/Patient(s) Information
Resident/Patient Name:
Date of Birth:
Relationship to Resident/Patient:
Is the Resident/Patient still in the facility?
Yes
No
Additional Name(s):
Name:
Date of Birth:
Relationship to Resident/Patient:
Is the Resident/Patient still in the facility?
Yes
No
Name:
Date of Birth:
Relationship to Resident/Patient:
Is the Resident/Patient still in the facility?
Yes
No
Section IV Alleged Wrongdoer(s) Information – if applicable or known
Name:
Title:
Additional Name(s)/Title:
Name and Title:
Name and Title:
Name and Title:
HEA1685 Rev. 4/08
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