File a Complaint

Date of Incident or Event:

Month

Day

Year

Person Filing the Complaint

Salutation:

Name:

First Last

Email:(Required)

Phone:

City:

Preferred Contact Method:

Preferred Contact Time:

Hour

Minute

Resident Name:

First Last

Is the resident a PACE participant?

What is your relationship to the resident?

Facility Name:

Facility Address:

Street Address Address Line 2 City State ZIP Code

County:

Does the resident still reside in the facility named above?

Does the resident know you are contacting the Long-Term Care Ombudsman for assistance?

Please explain the nature of your concern or complaint: