CONCERN/GRIEVANCE REPORTING FORM
FACILITY NAME (check one):
DATE
:
Cortland
Hartford
Milan
Sandusky
Toledo
COMPLAINANT NAME
(NOT REQUIRED)
ARE YOU A: Resident
Family Member
Employee
Other
Telephone
E-mail
NATURE OF CONCERN/GRIEVANCE, OR DETAILS OF INCIDENT:
Resident involved:
Name
Room#
Employees involved
Names
Date of incident:
SPECIFIC QUESTIONS OR COMMENTS
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