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An Official
Pennsylvania
Government Website
Department of Human Services
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
Please select an option
Alabama
Alaska
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Pennsylvania
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South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Zip Code (e.g. 17000 or 17000-0000)
Phone Number (e.g. 555-555-5555)
Alternate Phone Number (e.g. 555-555-5555)
Email
Relationship to Resident
Self
Spouse
Sibling
Significant Other
Aunt/Uncle
Parent
Grandparent
Child
In-Law
Staff
Neighbor
Other
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
Please select an option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Facility Zip Code (e.g. 17000 or 17000-0000)
Facility County
Please select an option
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Complaint Information
Complaint Type
New Complaint
Recently Lodged Complaint
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)
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