MARYLAND
Department of Health
Office of Health Care Quality
7120 Samuel Morse Drive • Second Floor • Columbia, MD 21046-3422
Phone 410-
402-8015
• Fax 410-402-8056 • ohcq[email protected]
COMPLAINT 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 additional sheet,
if necessary. You may use this form as a guide when making a complaint by telephone. We will
investigate your concerns based on the information that you provide.
You may file an anonymous complaint
Complete the following questions.
1. Name of patient/resident/client involved in the incident:
Date of Birth: _______________
Date of Admission: ____________________
2. Health care facility, residence, or community treatment program involved in the incident:
Name:
Address:
Check the type of facility or program: [ ] Nursing home [ ] Adult medical day care [ ] Assisted
living [ ] Hospital [ ] Home health agency [ ] Hospice [ ] Dialysis Center [ ] [ ] Ambulatory surgery
center [ ] Residential services agency
[ ] Medical laboratory [ ] Developmental disabilities provider
[ ] Other. Please specify:
3. Witnesses to the incident:
Name Contact information, if known (include telephone number)
_____________ ______________ ______________ __________________________________
4. Person filing complaint or reporting incident (optional).
Name: Relationship: __________________________
Address:
Telephone: ________
May we reveal your identity during the investigation of your complaint? [ ] Yes [ ] No
5. Have you reported this incident or concern to the person in charge of the facility, residence or
program? [ ] Yes [ ] No
6. Briefly describe the incident or your concerns (use additional paper 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.
