Patient Complaint/Grievance Resolution (PCGR) Form

Today's Date:

Name:

Address:

Phone:

Date/Time/Place of Complaint or Incident:

Name(s) of person(s) this grievance involves:

Name(s) of any Witness(es) present: Please check the option(s) below which best provide a general description of the grievance reported. 

 

Accident, Without Injury	Lack of Consent	Safety Violation
Behavioral, Agressive	Medical Emergency	Sexual Harrassment
Behavioral, Dangerous	Medication Error	Substance Abuse
Behavioral, Disruptive	Missing Person	Threats
Behavioral, Inappropriate	Neglect	Vehicular Concern/Problem
Community Concern	Physical Assault	Verbal Abuse
Compliance Concern	Property, Damage	Vehicular Concern/Problem
Death	Property, Missing	Other
Illness	Quality of Care Concern
Injury	Refusal of Care

 

Please provide an objective account of your observations regarding this grievance.

Do you request a follow-up response? Yes No