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Report of Complaint
 
This report is prepared for the review of the Quality Assurance Committee and Board of Directors. The contents of this report are confidential and protected by RCW 70.41.202 and RCW 4.24.250.
 
Name of Complainant: ___________________________________ Date: _________________
Address of Complainant: _________________________________ Time: _________________
                                     __________________________________ Telephone (   )__________
 
? Patient          ?Physician        ?Visitor     ?Other: __________________________________
Response Requested: ?Yes      ?No
Therapist/Clinician Name: ________________________________
Physician Name: ________________________________________
(if applicable)
Person Taking Report: ___________________________________________________________________
                                            Printed Name/Signature                                                                Job Title
 
Complaint Type:    ?Attitude      ?Clinical Care      ?Communication      ?Delay in Service
                                 ? Other: _________________________________________________
 
Concern/Complaint: _____________________________________________________________
                                     _____________________________________________________________
 
Plan of Action: _________________________________________________________________
                           _________________________________________________________________
 
Follow-up: ____________________________________________________________________________
                    ____________________________________________________________________________
 
____________________________________            ___________________________________________
Signature of Complainant                                                       Signature of Person Taking Report
 
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