Complaint Form Your contact information(This information will be kept confidential)Name First Last PhoneEmail Relationship to the senior you are filing a complaint about:If you are a professional, what agency do you work for?If you are a mandatory reporter, have you filed a report with central intake?YesNoPersonal information about the senior you are concerned aboutName First Last Date of birth Date Format: MM slash DD slash YYYY AgePlease enter a number from 50 to 120.GenderMaleFemaleInformation about where this senior livesAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of facility (if applicable):Phone number of facility:Pay Source Information for the seniorSourceWaiverGeneral ReliefPrivate PayUnknownRepresentationDoes the senior have a legal representative?YesNoUnknownSenior's Legal RepresentativeTypeGuardianConservatorPOAOtherRepresentative Name First Last Representative PhoneRepresentative Email Representative Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other people who may have information regarding this situationDo any other people have information about this situation?YesNoPerson who may have information (1)Relationship to seniorFamily memberCare CoordinatorOtherName First Last PhoneEmail Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do any other people have information about this situation? (2)YesNoPerson who may have information (2)Relationship to seniorFamily memberCare CoordinatorOtherName First Last PhoneEmail Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do any other people have information about this situation? (3)YesNoPerson who may have information (3)Relationship to seniorFamily memberCare CoordinatorOtherName First Last PhoneEmail Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do any other people have information about this situation? (4)YesNoPerson who may have information (4)Relationship to seniorFamily memberCare CoordinatorOtherName First Last PhoneEmail Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other InformationIs senior able to effectively communicate?YesNoAdditional information regarding the senior’s condition or impairmentDoes the senior want the LTC Ombudsman’s assistance with this issue?YesNoI don't knowDo you give your permission for the LTC Ombudsman to investigate this complaint including sharing this information with other agencies?YesNoDo you wish to remain anonymous about who filed this complaint?YesNoDoes the senior wish to remain anonymous about this issue?YesNoI don't knowDetails about the complaint*(date/time, what happened, who was involved in the situation, were there other witnesses, do you have photos)What action has anyone taken to resolve the complaint so far?Reported to other agencies, police, etc. What do you see as a good resolution of the complaint?CommentsThis field is for validation purposes and should be left unchanged. 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