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.

 

I. Name of patient/resident/client involved in the incident:
II. Health care facility:
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.
IV. Witnesses to the incident:
V. Person or entity
Note: If you would like a report that may result from our investigation, please complete this section.
Report of incident or Concern

Provide name and position of person(s).

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