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CONCERN/GRIEVANCE REPORTING FORM

FACILITY NAME (check one): DATE:
Cortland    Hartford     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
  

Concord Care Centers