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Ombudsman Complaint Form

Please complete this confidential form to request assistance in advocating for yourself or your loved one living who resides in a nursing home or assisted living home. We understand that you may not have access to all the information requested, but please be complete as much as possible. An Ombudsman will contact you if you provide your contact information. You may also file a complaint with the facility's licensing agency, Office of Health Care Quality.

Relationship to Resident
Do we have permission to reveal your identity during our complaint investigation?
Is the resident capable of making decisions?
Complaint Summary: Note: Include dates, times, persons involved, witnesses and description of the incident(s). If reporting anonymously, be complete since we will not be able to obtain more information from you.
Have you notified the facility staff with this complaint?
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