Online Complaint Intake for Personal Care Homes and Assisted Living Residences

Fields marked with * are required

Contact Information:

Your First Name

Your Last Name

Address

City

State

Zip Code (e.g. 17000 or 17000-0000)

Phone Number (e.g. 555-555-5555)

Alternate Phone Number (e.g. 555-555-5555)

Relationship to Resident

Please specify if "Other"

Resident Information

Resident First Name

Resident Last Name

Resident Date of Birth (e.g. MM/DD/YYYY)

Date of Incident

Facility Information

Facility Name

Facility Address

Facility City

Facility State

Facility Zip Code (e.g. 17000 or 17000-0000)

Facility County

Complaint Information

Complaint Type

Confidentiality Requested (will allow DHS to be in touch regarding outcome of investigation, facility will not be informed who lodged the complaint.)

Concerns Discussed With (e.g. Name & Title of Facility Staff)

Follow Up Requested (All complaints will be reviewed daily and will be prioritized for investigation. If Follow-Up Requested is checked, a notification will be sent as an alert that the investigation has been concluded and whether or not it has been substantiated.)

Details (Please be as specific as possible)

Generate a new image Play the audio code

Enter the code from the image