Report a Complaint about a Health Care Organization Health Care Organization Information Complete the three steps below. In step 3, only health care organizations accredited and previously accredited by the Joint Commission are included in the list. 1. Select the state/country 2. Select the city where the 3. Select the health care organization where the where the incident occurred: incident occurred: incident occurred:    Select... FPO (North and South America) ALBERTA FPO (Europe Africa Middle East Canada) ALASKA ALABAMA FPO (Pacific) ARKANSAS AMERICAN SAMOA ARIZONA BRITISH COLUMBIA CALIFORNIA COLORADO CONNECTICUT CANAL ZONE DISTRICT OF COLUMBIA DELAWARE FLORIDA FEDERATED STATES OF MICRONESIA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MANITOBA MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI NORTHERN MARIANA ISLANDS MISSISSIPPI MONTANA NEW BRUNSWICK NORTH CAROLINA NORTH DAKOTA NEBRASKA NEWFOUNDLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NOVA SCOTIA NORTHWEST TERRITORIES NEVADA NEW YORK OHIO OKLAHOMA ONTARIO OREGON PENNSYLVANIA PRINCE EDWARD ISLAND PUERTO RICO PALAU QUEBEC RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA SASKATCHEWAN TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING YUKON TERRITORY If you DID NOT find the name of the health care organization from the list in step 3 above, complete the    information below.  Please leave this section blank if you were able to find the organization in the above section.  Enter the name only if the organization is located outside the United States.  Organization Name: Country:   Organization Street Address: City: State: Zip Code:   Select... ALASKA ALABAMA ARKANSAS AMERICAN SAMOA ARIZONA CALIFORNIA COLORADO CONNECTICUT CANAL ZONE DISTRICT OF COLUMBIA DELAWARE FLORIDA FEDERATED STATES OF MICRONESIA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI NORTHERN MARIANA ISLANDS MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO PALAU RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Organization Phone Number Type of Organization     Select... Ambulatory Care Facility Ambulatory Surgical Center Common Areas Community Health Center Community Mental Health Center Dementia Special Care Unit Dialysis Center Group Medical Practice Home Health Care Hospice Hospital ICU Infertility Center Labor/Delivery Long Term Care Facility Nursery Patient Room Quality Assurance Recovery Room Residential Treatment Center Single Specialty Center Skilled Nursing Facility Subacute Care Program Unknown Urgent/Emergency Care Centers Veteran Administration Program Personal Information Complete the information below if you would like the Joint Commission to notify you about any action taken on your complaint. Your name will be kept confidential. Salutation: Select... Adm. BG Br. Capt CDR Cmdr COL Col. CPT Cpt. Dr. GEN Lt. Lt.Col Lt.Gen LTC Ltc. LtCmdr Maj. MajGen Miss MP Mr. Mr/Mrs Mrs. Ms. RDML Rev. Sister First Name: Middle Initial: Last Name: Personal Credentials: Select... Esq. II III IV Jr. Sr. Professional Credentials: Select... ACSW DDS DO DPM EdD JD LCSW MD OT Other Professional PharmD PhD PT RN RT SLP Firm Name: Street Address: City: State: Select... ALASKA ALABAMA ARKANSAS AMERICAN SAMOA ARIZONA CALIFORNIA COLORADO CONNECTICUT CANAL ZONE DISTRICT OF COLUMBIA DELAWARE FLORIDA FEDERATED STATES OF MICRONESIA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI NORTHERN MARIANA ISLANDS MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO PALAU RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Zip: Telephone: Ext: Fax: Ext: Email: I am:  *Required Select... Accredited Organization - Administration Advocacy Agency Anonymous Attorney CAP CMS Employee (current) Employee (former) Family/significant other of patient Federal Agency Insurance company JCAHO Employee Managed Care Management Media Other/Not Stated Patient Performance Measurement Data - ORYX Physician Professional-RN,RPH,PT,OT,etc. Public / General State Licensing Agency Technicians Do you wish to remain anonymous? *Required Select... No Yes Incident Information Incident Date: *Required Incident Narrative (Provide a brief overview of your complaint) Disclaimer When submitting a complaint to the Joint Commission about an accredited organization, you may either provide your name and contact information or submit your complaint anonymously. Providing your name and contact information enables the Joint Commission to inform you about the actions taken in response to your complaint, and also to contact you should additional information be needed. It is our policy to treat your name as confidential information and not to disclose it to any other party. However, it may be necessary to share the complaint with the subject organization in the course of a complaint investigation. Joint Commission policy forbids accredited organizations from taking retaliatory actions against employees for having reported quality of care concerns to the Joint Commission. Contact Agreement May we contact you if we need more information related to the incident? *Required Select... No Yes © 2009, The Joint Commission