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Welcome to the Division of Quality Assurance (DQA) Complaint Intake Survey, F-00607 (09/2019)

You may use this survey to register a complaint about care received at a:
  • Nursing home
  • Assisted living facility (adult day care, adult family home, community-based residential facility, or residential care apartment complex)
  • Hospital, home health, hospice
  • Other facility or program regulated by DQA
     
1. Source of Complaint: What is your connection to the person or provider noted in the complaint? *This question is required.
We recommend that you supply contact information in case we have follow-up questions regarding your complaint submission.
This question requires a valid number format.
10. Best days to call you
This question requires a valid email address.
13. Do you wish to remain anonymous to the facility or staff person(s) that is the subject of your complaint? *This question is required.
14. My complaint is about care provided by/at a: *This question is required.
18. Is your complaint about a specific facility staff person? *This question is required.
19. Does your complaint concern a specific resident, patient, or client of the facility named above? *This question is required.
Are you the legal guardian or the activated power of attorney for health care (POAHC) of the resident, patient, or client?
This question requires a valid date format of MM/DD/YYYY.
calendar
22. Was the incident described above reported to facility staff? *This question is required.
23. Was the incident described above reported to other agencies? *This question is required.