Kansas Department of Health and Environment: Facility Complaint Investigation Form

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KDHE Home - Health - Bureau of Health Facilities - Hospital LTCU Complaint Form

Facility Complaint Investigation Form

Available below is a Portable Document Format (.pdf) version of the Facility Complaint Investigation Form. The form is to be used only by KDHE regulated hospital long term care units in reporting the results of self-investigated allegations of abuse, neglect and/or exploitation. Users of this form must contact the Bureau of Health Facility's Complaint Program to receive a report case number which must be entered on the form where indicated. The Complaint Hotline number, 1-800-842-0078 , should be used to obtain the case number. The Hotline is staffed from 8 A.M to Noon and from 1:00 P.M. to 4:00 P.M. Monday through Friday. The completed form and accompanying documentation must be sent to the Bureau of Health Facility's State Survey Manager (see p. 2 of the form for contact information) within 7 days of the Complaint Program's receipt of the initial complaint.

To fill out the Facility Complaint Investigation form, you will need to have the latest version of Adobe Acrobat Reader software. This software is available for free download at: http://www.adobe.com/products/acrobat/readstep2.html The investigation form is made available as an interactive document. Thus it can be completed on screen by using the mouse to click on a particular field or by using the Tab key to move from field to field. (Use Shift - Tab to move backwards in the form.) The completed form can be printed by either using the PRINT button in the top left hand corner of the menu bar or by using the Print command from your software's menu. The form can be RESET (i.e. all fields are cleared) by using the 'CLEAR FORM' feature from the software's menu bar. Once the form is completed and printed, it must then be signed on page 2 before submission to the State Survey Manager .

COMPLAINT INVESTIGATION REPORT FORM (REVISED 04/07)