FLIS Complaint Submission Page

FLIS Complaint Submission

Report a New Complaint

* - Required Field

Section 1. Person Filing Out the Complaint Form Information

First Name

Last Name

Address

City

State

Zip Code

Primary Phone

Cell Phone

Section 2. Facility Information

Facility Name

Address

City

State

Zip Code

Section 3. Patient Information

Patient Related?

Yes No *

First Name

Last name

Date of Birth (If Known)

Is the patient still in the facility?

Yes No Do not know

Your relationship to the Patient

Section 4. Complaint Information (20000 Characters Max)

Names of any other person(s) or witness(es) involved in this complaint

Person 1 / Witness 1

First Name

Last Name

Contact Info

Person 2 / Witness 2

First Name

Last Name

Contact Info

Section 5. Reporting of Complaint

Did you report this complaint to the facility staff?

Yes No

A. Date the Complaint was reported to the facility staff person:

B. Name and title of the facility staff person to whom the complaint was reported:

C. What action was taken by the facility?

Upon Clicking Continue to Review and Submit button you will be able to upload documents/pictures pertaining to this complaint

DEPARTMENT OF PUBLIC HEALTH

DPH FLIS - Facility Licensing & Investigations Section(FLIS)