[DC GOVERNMENT] DOH Complaint / Incident Report Form

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DOH Complaint / Incident Report Form

Complete this form if you have concerns about the health care or treatment that you or a family member received or did not receive. Answer all questions. Give complete details. Use as much space as necessary. We will investigate your concerns based on the information that you provide. You may file an anonymous complaint. You may use this form as a guide when making a complaint by telephone. Our complaint hot line Number is (202)442-5833.

Gender

Male

Female

Age

Room# (If Known)

Name

Provider # (If Known)

If Other, Please specify

Include dates and times, persons involved, and description of what happened. Include attachments, if appropriate. Note: If this is an anonymous report, be complete since we will not be able to contact you to obtain missing information, which may impede the investigation.

Phone Number

Witness email

Would you like a report that may result from our investigation?

Yes

Relationship

Phone Number

May we reveal your identity during the investigation of your complaint?

Yes

VI. Have you reported this incident or concern to the person in charge of the facility, residence or program?

Yes

Provide name and position of person(s).

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DOH Complaint / Incident Report Form

Gender

Check the type of facility or program:

V. Person or entity filing complaint or reporting incident:

Would you like a report that may result from our investigation?

May we reveal your identity during the investigation of your complaint?

VI. Have you reported this incident or concern to the person in charge of the facility, residence or program?

DOH Complaint / Incident Report Form

Full Name

Gender

Full Address

Check the type of facility or program:

Full Name

V. Person or entity filing complaint or reporting incident:

Would you like a report that may result from our investigation?

Full Name

Full Address

May we reveal your identity during the investigation of your complaint?

VI. Have you reported this incident or concern to the person in charge of the facility, residence or program?