Hospital Clinical Staffing Complaint Form

Have you filed a complaint with the hospital’s Clinical Staffing Committee?
If NO, you should first file a complaint with the hospital’s Clinical Staffing Committee prior to submitting this form. If you are unable to file a complaint with the hospital’s Clinical Staffing Committee, please provide a detailed description explaining why and continue with the submission of this form. 
Is this the first complaint you’ve filed with the hospital’s Clinical Staffing Committee regarding this particular issue?
Has the hospital’s Clinical Staffing Committee completed a review of this complaint?
If YES, what were the results of their review
Do you wish to remain anonymous to the hospital?
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 patient's name with the facility. Please do not attach any additional information such as medical records, as it will not affect the outcome of the decision.
Complaint type
Facility Information info
Choose an item.
Click or tap to enter a date.
CAPTCHA
9 + 11 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.