"Complaint Form" - Ohio

Complaint Form is a legal document that was released by the Ohio Board of Nursing - a government authority operating within Ohio.

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Rate (4.6 / 5) 82 votes
         
 
COMPLAINT   F ORM  
 
All   c omplaints   a re   k ept   c onfidential   p ursuant   t o   S ection   4 723.28(I),   O RC   a nd   a re   n ot   a   p ublic   r ecord.  
 
Instructions:   Y ou   m ay   d ownload   t his   f orm,   c omplete   i t   o n   y our   c omputer,   s ave   i t   a s   a   W ord   d ocument,   a nd   e -­‐mail   i t   a s   a n  
attachment,   t o  
c
omplaints@nursing.ohio.gov.     O r   y ou   m ay   f ax   t he   c ompleted   f orm   t o   6 14-­‐995-­‐3686   o r   6 14-­‐995-­‐3685,   o r   s end  
via   r egular   m ail   i t   t o   t he   B oard’s   O ffice,   A tt’n   C ompliance   U nit,   a t   t he   a ddress   l isted   a bove   i n   t he   l etterhead.      
If   y ou   h ave   q uestions,   p lease   c all   6 14-­‐466-­‐9564.  
 
Under   H IPAA,   t he   B oard   i s   a   h ealth   o versight   a gency   t o   w hom   r elease   o f   P HI   i s   a   p ermitted   d isclosure   w ithout   p atient  
authorization.     4 5   C FR   1 64.512(d).  
 
Complainant   I nformation  
Date  
 
 
Name   o f   p erson   f iling   c omplaint   a nd   T itle/Position   ( if   a pplicable)      
 
 
Home   A ddress  
                                                 
I nclude   C ity,   S tate   &   Z ip  
Home   T elephone  
 
E-­‐Mail   A ddress  
 
 
Filing   o n   b ehalf   o f   a n   a gency   o r   f acility?  
  Y es    
    N o     ( If   y es,   p lease   p rovide   i nformation   r equested   b elow)  
 
    a gency/facility   n ame  
 
 
  a gency/facility   a ddress
           
 
 
 
   
I nclude   C ity,   S tate   &   Z ip
a gency/facility   t elephone  
  Y our   E -­‐Mail   A ddress   ( at   f acility)  
 
   
 
Complaint/Incident   I nformation  
Please   p rovide   a s   m uch   i nformation   a s   p ossible.     T he   B oard   u nderstands   t hat   y ou   m ay   n ot   k now   a ll   o f   t he   i nformation.  
 
Date   o f   i ncident_
___
)
Name  
( of   t he   p erson   y ou   a re   r eporting   t o   t he   B oard
Home   A ddress  
 
                                               
I nclude   C ity,   S tate   &   Z ip  
 
Home   T elephone   #
                                                                                    E -­‐Mail   A ddress
 
 
Please   c heck      
    A dvanced   P ractice   N urse     ( CNP,   C NS,   C RNA,   C ertified   N urse   M id-­‐Wife)  
R egistered   N urse      
L icensed   P ractical   N urse  
   
   
D ialysis   T echnician    
C ommunity   H ealth   W orker      
 
   
C ertified   M edication   A ide        
N o   L icense   o r   C ertificate    
   
   
 
License   o r   C ertificate   N o.  
                        L ast   4   S SN  
   
D.O.B.  
 
 
Employer  
 
 
              D ate   o f   H ire  
 
 
 
Employer’s   A ddress  
                                                                                                   
I nclude   C ity,   S tate,   &   Z ip  
Employer   T elephone   #  
         
 
Employer   E -­‐Mail   A ddress
 
         
 
COMPLAINT   F ORM  
 
All   c omplaints   a re   k ept   c onfidential   p ursuant   t o   S ection   4 723.28(I),   O RC   a nd   a re   n ot   a   p ublic   r ecord.  
 
Instructions:   Y ou   m ay   d ownload   t his   f orm,   c omplete   i t   o n   y our   c omputer,   s ave   i t   a s   a   W ord   d ocument,   a nd   e -­‐mail   i t   a s   a n  
attachment,   t o  
c
omplaints@nursing.ohio.gov.     O r   y ou   m ay   f ax   t he   c ompleted   f orm   t o   6 14-­‐995-­‐3686   o r   6 14-­‐995-­‐3685,   o r   s end  
via   r egular   m ail   i t   t o   t he   B oard’s   O ffice,   A tt’n   C ompliance   U nit,   a t   t he   a ddress   l isted   a bove   i n   t he   l etterhead.      
If   y ou   h ave   q uestions,   p lease   c all   6 14-­‐466-­‐9564.  
 
Under   H IPAA,   t he   B oard   i s   a   h ealth   o versight   a gency   t o   w hom   r elease   o f   P HI   i s   a   p ermitted   d isclosure   w ithout   p atient  
authorization.     4 5   C FR   1 64.512(d).  
 
Complainant   I nformation  
Date  
 
 
Name   o f   p erson   f iling   c omplaint   a nd   T itle/Position   ( if   a pplicable)      
 
 
Home   A ddress  
                                                 
I nclude   C ity,   S tate   &   Z ip  
Home   T elephone  
 
E-­‐Mail   A ddress  
 
 
Filing   o n   b ehalf   o f   a n   a gency   o r   f acility?  
  Y es    
    N o     ( If   y es,   p lease   p rovide   i nformation   r equested   b elow)  
 
    a gency/facility   n ame  
 
 
  a gency/facility   a ddress
           
 
 
 
   
I nclude   C ity,   S tate   &   Z ip
a gency/facility   t elephone  
  Y our   E -­‐Mail   A ddress   ( at   f acility)  
 
   
 
Complaint/Incident   I nformation  
Please   p rovide   a s   m uch   i nformation   a s   p ossible.     T he   B oard   u nderstands   t hat   y ou   m ay   n ot   k now   a ll   o f   t he   i nformation.  
 
Date   o f   i ncident_
___
)
Name  
( of   t he   p erson   y ou   a re   r eporting   t o   t he   B oard
Home   A ddress  
 
                                               
I nclude   C ity,   S tate   &   Z ip  
 
Home   T elephone   #
                                                                                    E -­‐Mail   A ddress
 
 
Please   c heck      
    A dvanced   P ractice   N urse     ( CNP,   C NS,   C RNA,   C ertified   N urse   M id-­‐Wife)  
R egistered   N urse      
L icensed   P ractical   N urse  
   
   
D ialysis   T echnician    
C ommunity   H ealth   W orker      
 
   
C ertified   M edication   A ide        
N o   L icense   o r   C ertificate    
   
   
 
License   o r   C ertificate   N o.  
                        L ast   4   S SN  
   
D.O.B.  
 
 
Employer  
 
 
              D ate   o f   H ire  
 
 
 
Employer’s   A ddress  
                                                                                                   
I nclude   C ity,   S tate,   &   Z ip  
Employer   T elephone   #  
         
 
Employer   E -­‐Mail   A ddress
 
Complaint   F orm  
Page 2 of 2  
Complaint/Incident   I nformation   C ont’d  
 
Has   t he   i nformation   r eported   i n   t his   c omplaint   b een   r eported   t o   a nother   a gency   o r   l aw   e nforcement   a uthority?        
Yes        
    N o  
 
If   y es,   p lease   s pecify   a nd   l ist   t he   c ontact   p erson  
 
Was   the   nurse/dialysis   techician/community   health   worker/certified   medication   aide   terminated   from  
employment   d ue   t o   t his   i ncident?
Yes        
    N o  
 
If   y es,   p lease   l ist   e ffective   d ate  
 
 
Please   provide   below   a   brief   description   of   complaint   or   violation,   including   names   of   witnesses   and/or   victims:  
(please  type  or  print  neatly)  
Please send all related documentation and witness statements confirming the
violation.  
Please   Note:     if   you   are   an   employer   and   are   reporting   a   nurse   who   has   been   involved   in   a   practice  
breakdown   ( including   b ut   n ot   l imited   t o   d ocumentation   i ssues,   f ailure   t o   f ollow   p hysician’s   o rders,   f ailure  
to   assess   a   patient,   failure   to   perform   treatments,   and   medication   errors)   please   complete   the  
Supplemental   I nformation   F orm   ( available   o n   t he   B oard’s   w ebsite   a t   w ww.nursing.ohio.gov.  
 
Please   p rovide   n ames,   a ddresses   a nd   t elephone   n umbers   o f   w itnesses   b elow
:    
Witness   # 1  
 
      W itness   # 2  
 
 
                   
N ame  
 
 
 
 
 
                      N ame  
 
 
 
     
 
 
 
A ddress   l ine   1  
                              A ddress   l ine   1  
 
 
     
     
 
 
Address   l ine   2  
                              A ddress   l ine   2
 
 
Telephone   #   a nd/or   e -­‐mail   a ddress  
 
    T elephone   #   a nd/or   e -­‐mail   a ddress  
 
Witness   # 3  
 
      W itness   # 4  
 
 
                   
N ame  
 
 
 
 
 
                      N ame  
 
 
 
     
 
 
 
A ddress   l ine   1  
                              A ddress   l ine   1  
 
 
     
     
 
 
Address   l ine   2  
                              A ddress   l ine   2
 
 
Telephone   #   a nd/or   e -­‐mail   a ddress  
 
    T elephone   #   a nd/or   e -­‐mail   a ddress  
 
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