- Complaint Tracking

Information

OFFICE OF HEALTH ASSURANCE AND LICENSING
OHIO DEPARTMENT OF HEALTH
COMPLAINT FORM

You may file this complaint ANONYMOUSLY, by NOT providing us your name and address. Skip toSection 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. Fields marked with * are mandatory

Section I Complainant Information

Complete only if you wish to receive our acknowledgement and 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 appicable or known

Name :

Title :

Additional Name(s)/Title:

Name and Title :

Section V Narrative Description

Provide a narrative description of your complaint which should include date, time and location of the incident. Include name and phone number of any witness(es), if applicable.*

Notes :