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Welcome to the Division of Quality Assurance (DQA) Complaint Intake Survey, F-00607 (02/2020)

You may use this survey to register a complaint about care received at a:
  • Nursing home
  • Licensed 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.

However, if you wish to remain anonymous, please check the "Yes" circle in the next question. If you remain anonymous, you will not be contacted by us or any other related / investigating entity and will not be able to receive any information regarding the investigation outcome.
2. Do you wish to remain anonymous to the facility or staff person(s) that is the subject of your complaint?
This question requires a valid number format.
3. Best days to call you
This question requires a valid email address.
3. Have you reported this incident and/or facility to DQA in the past?
4. My complaint is about care provided by/at a: *This question is required.
8. Is your complaint about a specific facility staff person? *This question is required.
9. 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.
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12. Was the incident described above reported to facility staff? *This question is required.
13. Were the local authorities or police called and/or involved at all with this incident? *This question is required.