(Please Print This Form Before Filling Out)
Complaint # _________________
Complaint/Suggestion Form
Southeast Regional Office DHR/MHDDAD
Consumer ____________________Male___ Female___
Address______________________________________________________________________
City__________________________State/Zip_________________DOB_________Age_______
Phone #_________________________________________________
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Complainant/Reporter_________________________________________Contact #________________
Relationship to Consumer: Family/Guardian_________Self-Reported________Anonymous________
Current Staff________ Ex-Staff______Other__________________________________
Address _____________________City__________________________State/Zip__________________
Phone # _______________________________________
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Type of Complaint:
___Access to Services
___Courtesy of staff
___Physical Surroundings
___Quality of Services
___Complaint about Healthcare Provider
___Other
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Allegations of abuse, neglect or exploitation should be reported through the incident report process rather than through a complaint. Please contact the Southeast Regional Office for information and forms.
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Please fax or mail complaint to: Southeast Regional MHDDAD Office, (912) 651-0968
7001 Chatham Center Drive, The Liberty Building, Suite 600, Savannah, GA 31405
Original: Regional Board
CC: Service Provider
Citizen Subcommittee
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Complaint # _____________________
Date of Complaint ___________ Time of Complaint ________________________________
Primary Provider ___________________________Sub-Contractor______________________
Residential _____Day Hab ______Other______
Location of Incident (Address, Phone#)________________________________________________________
________________________________________________________________________________________
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Type of Complaint:________________________________________________________________________
Have you made this complaint previously? ____________________________________________________
If so, to whom?__________________________________________________________________
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Disability(ies) DD____MH____AD____ Complaint Priority: Urgent____ Regular____
Concerns/Allegation______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
How would you like to see this complaint resolved? ____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Resolution:______________________________________________________________________________
________________________________________________________________________________________
Staff taking complaint:_______________________________________
Date Resolved:_____________________________________________
Original: Regional Board
C.C. Service Provider
Citizen Subcommittee