Facility Information

Name of Facility
Street Address

Person Reporting

Do you wish to remain anonymous to the facility (Yes or No)?YesNo

First Name

Last Name

Email Address

Contact Number

Relationship to Resident

Resident Information

First Name

Last Name

Contact Number

Room Number

Complaint

Describe the event: Provide a detailed description of the complaint.

Once your complaint is received, it will be reviewed by an Ombudsman representative. If you have provided a contact number, you may receive a call from the designated Ombudsman seeking additional information to resolve your complaint.