Please complete the form below to the best of your abilities. When finished, click once on the "Submit Complaint" button at the bottom of the page to submit the form for processing.
Your First Name:
Your Last Name:
Title:
Relationship to Licensee:
Agency or Organization:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Email Address:
Phone Number/Extension:
Your Complaint is Against (Licensee):
Please complete as many of the fields below as you can.
Licensee First Name:
*
Licensee Last Name:
*
License Type:
CNA LPN NP Other CMA RN CRNA
License # (if known):
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Email Address:
Phone Number/Extension:
Licensee's place of work (Facility):
Licensee's Supervisor:
Licensee's Supervisor's Phone:
Complaint Facts: * Be sure to include as many fact pertaining to the
complaint as possibly, including: dates, times and locations of incidents; behaviors
of respondent which were observed by you; any statements or admissions made by
respondent.
How did you become aware of the incident or concern?
Date of Incident: [MM/DD/YYYY]
*
Location of Incident:
*
Patient's First Name:
*
Patient's Middle Initial:
Patient's Last Name:
*
Patient's Date of Birth: [MM/DD/YYYY]
/
/
Patient's Medical Record #:
Have you filed this complaint elsewhere (facility, Adult Protective Services, law enforcement)?:
Yes
No
Witness Information:
Be sure to include full witness names, addresses and telephone numbers, and statements
made by the witness(es) regarding incidents.
Supporting Documentation:
Please use the fields below to attach copies of any relevant supporting documents such as patient record including patient name and/or medical record number, incident reports, memos, written statements, narcotic count sheets, Pyxis reports, narcotic audits, urine drug screen results, anecdotal/counseling notes, time cards, pertinent policies and procedures. Alternatively you can email supporting documentation to
debra.steiner@state.or.us or fax to (971) 673-0684.
NOTE: If your file(s) are larger than 10MB, please fax or email them using the info above.
I verify that the statements are true in every respect; that I have not suppressed
any information that would affect this complaint; that I will conform to ethical
standards of conduct and obey the laws and rules of the Oregon State Board of Nursing;
that I have read and understood that failure to disclose the requested information
or disclosure of false information or disclosure of misleading information may constitute
fraud and may result in criminal prosecution.
By clicking the "SUBMIT COMPLAINT" button, you agree to the above Verification by Oath or Affirmation.
