Complaint Form

* Required Information

Patient *

Date *

Name of person filing the complaint if not the patient

Relationship to the patient

Name/title of who received the initial complaint *

Date *

Was the complaint logged in complaint log book? *

Yes

Description of the complaint

Resolution of the compliant (action taken)

Follow up needed

Date complainant was notified of proposed resolution (within 30 days) *

Was the person making the complaint satisfied with the resolution and/or action plan? *

Yes

If no what follow up was implemented?

I have reviewed and ensured the implementation related to this complaint including any follow up needed.

Signature *

Title*

Date

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