We Can Help
Call 24/7: 336-889-8446
Back to Continuing Education

Consumer Complaint Record

Nov 8, 2021

Consumer Complaint Record
Opportunity to Improve Organizational Performance

MM slash DD slash YYYY
Time complaint receivd(Required)
:
Person receiving complaint(Required)
Name of patient involved(Required)
Patient status
Name of employee involved (if not applicable to this incident, enter N/A)
Name of person making complaint
Location (address/facility)(Required)
How complaint was received(Required)
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.
MM slash DD slash YYYY

Once completed, scroll to bottom and click Save and Submit.

Follow up/Resolution

To be completed by supervisor.
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.