Online Complaint Intake

Fields marked with * are required

Contact Information:

Your First Name

Your Last Name

Address

City

State (e.g. PA)

Zip Code (e.g. 17000)
Contact Zip Code is invalid

Phone Number (e.g. 555-555-5555)
Phone Number must be of the form (xxx)xxx-xxxx or xxx-xxx-xxxx

Alternate Phone Number (e.g. 555-555-5555)
Alternate Phone Number must be of the form (xxx)xxx-xxxx or xxx-xxx-xxxx

Email
Email Address is invalid

Complaint Type
New Complaint
Recently Lodged Complaint

Confidentiality
Confidentiality Requested
Confidentiality Requested - will allow DOH to be in touch regarding outcome of investigation, facility will not be informed who lodged the complaint.

Relationship to Patient

Please specify if "Other":

Patient Information:

Patient First Name

Patient Last Name

Patient Date of Birth (e.g. MM/DD/YYYY)

Date of Incident (e.g. MM/DD/YYYY)

Facility Information:

Facility Name*

Facility Address*

Facility City*

Facility State* (e.g. PA)

Facility Zip Code* (e.g. 17000)
Facility Zip Code is invalid

Complaint Information:

Concerns discussed with:

Administrator

Director of Nursing

Other Staff

Details (Please be as specific as possible)*