complaints_compliments
complaints_compliments
complaints_compliments
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Sample Form For Recording Resident Family Complaints/Concerns<br />
Person Voicing Concern<br />
Date<br />
Resident’s Name Unit #<br />
How to Contact:<br />
Address<br />
Day Phone<br />
Evening Phone<br />
Describe the complaint/concern:<br />
Expectations of person voicing concern:<br />
Referred to: Dept. Date of Referral<br />
Findings:<br />
Actions Taken:<br />
Reportable to an outside agency? Yes No<br />
If yes, was this reported? Yes No<br />
To whom:<br />
Date<br />
Investigation findings reported to person voicing concern? Yes No<br />
How? In-person In writing Telephone<br />
Notes:<br />
Person voicing concern satisfied with findings and action? Yes No<br />
Person Completing Inquiry<br />
Date<br />
(Reprinted from “The Facility-Based Risk Management Program”)<br />
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