Department of Health

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DC Department of Health: Administrations & Offices: Health Regulation Administration

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:

Last Name:

First Name:

Sex:
Male Female

Age:

Room # (If Known)

II. Health care facility:

Name:

Provider # (If Known)

Address - Street & Number:

City:

State:

Zip Code:

Check the type of facility or program:

Nursing Home
Hospital
Home Health Agency
Hospice
Dialysis Center
Ambulatory Surgical Center
Birthing Center
Medical Laboratory
Group Homes for the Mentally Retarded
Other. Please specify:

III. Briefly describe the incident or your concerns (use additional space if necessary):

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:

Name:

Contact information, if known (include telephone number):

V. Person or entity filing complaint or reporting incident (optional):

Note: If you would like a report that may result from our investigation, please complete this section.

01 Resident/Patient/Client
02 Former Staff Member
03 Anonymous
04 Ombudsman
05 Receiving Entity
06 Congressional Inquiry
07 Medicare Intermediary Carrier
08 Entity (Self Reported)

09 Current Staff Member
10 Family Member
11 Coroner (Medical Examiner)
12 CMS
13 Transferring Entity
14 Quality Improvement Organization
15 State Surveyor
99 Other

Name:

Relationship:

Address:

City:

State:

Zip Code:

Telephone:

May we reveal your identity during the investigation of your complaint?
Yes No

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

No
Yes. Provide name and position of person(s).
Name Position