Back to Resources Consumer Complaint Record Nov 8, 2021 Consumer Complaint Record Opportunity to Improve Organizational Performance Date complaint received(Required) MM slash DD slash YYYY Time complaint receivd(Required) Hours : Minutes AM PM AM/PM Person receiving complaint(Required) First Last Email of person receiving complaint Name of patient involved(Required) First Last Patient status Referral Active Bereavement Name of employee involved (if not applicable to this incident, enter N/A) First Last Name of person making complaint First Last Relationship to patient Phone number(Required)Location (address/facility)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How complaint was received(Required) Letter (scan and email to [email protected]) In person By phone ComplaintSignature of person completeing form By submitting this form, you are electronically signing this Consumer Complaint Record as the name listed above. This form will be submitted to the Quality and Compliance Team and forwarded on to other appropriate members of leadership.Date MM slash DD slash YYYY Once completed, scroll to bottom and click Save and Submit. Follow up/ResolutionTo be completed by supervisor. Follow up/resolution detailsSignature of person responding By submitting this form, you are electronically signing this Consumer Complaint Record. This form will be submitted to the Quality and Compliance Team and forwarded on to other appropriate members of leadership.
