Discipline and Complaints - File A Complaint or Self-Report Form

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. If you have questions about when to report, please see our Complaint Evaluation Tool.

NOTE: You will receive an email confirmation with the contents of your form submission once the form has been successfully submitted.

Please complete all required (*) fields below with your information.



Your (Complainant or Self-Reporter) Information:
(Optional; however, please note that anonymous complaints can be harder to investigate and that we cannot provide any follow-up information to you if you file the complaint anonymously)
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:  
I would like to be informed regarding the outcome of this complaint:


Your Complaint is Against (Licensee):
Please complete as many of the fields below as you can.
Licensee First Name: *  
Licensee Last Name: *  
License Type:
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 Work Address Line 1:
Licensee's Work Address Line 2:
Licensee's Work Address City:
Licensee's Work Address State:
Licensee's Work Address Zip Code:
Licensee's Supervisor:
Licensee's Supervisor's Phone:
Licensee Employment Status (if known):

Complaint Facts: *

Be sure to include as many facts pertaining to the complaint as possible, including: dates, times and locations of incidents; behaviors of respondent which were observed by you; any statements or admissions made by respondent.


 
Date of Incident: [MM/DD/YYYY] / / *        
Location of Incident:
Location of Incident Address Line 1:
Location of Incident Address Line 2:
Location of Incident Address City:
Location of Incident Address State:
Location of Incident Address Zip Code:

Patient Information:
The Board is a health professional regulatory agency that is authorized to receive HIPAA protected information without a signed authorization, pursuant to Federal Title 45 CFR ยง 164. To view full language, click here.
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)?:  

Witness Information:
Witness' First Name::
Witness' Last Name:
Witness' address line 1:
Witness' address line 2:
Witness' address city:
Witness' address state:
Witness' address zip code:
Witness' Email Address:
Witness' Phone:
Witness Statement:

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 roberta.poole@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.







Verification by Oath or Affirmation:
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.

Submitting Complaint. Please wait.

 

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