Adult Care Facility and Assisted Living Program Complaint Form

Providing information about you will allow Department staff to contact you should additional information be needed. It is our policy to keep your name confidential. It may be necessary to share the nature of your complaint or the resident's name or your name with the facility. However, if you wish to remain anonymous, you may indicate that below.  In those cases, your information will not be shared and you will not receive any follow-up related to your complaint.

Your Contact Information
Name
Address
Do you wish to remain anonymous? (See above explanation)
Resident Information
Resident Name
Current Location
Facility Information
Complaint Information
Is law enforcement involved?
Have you filed a complaint with the facility?
If yes, who at the facility did you notify of the complaint?
Has your concern been resolved?
CAPTCHA