Prime Labor & Staffing

ONLINE COMPLAINT FROM

Health Care Organization Information

Complete the two steps below.

1. Select the Facility	2. Identify your
where the incident occurred:	unit or department

Personal Information

Complete the information below if you would like Prime Labor to notify you about any action taken on

your complaint. Your name will be kept confidential.

Salutation:
First Name:
Middle Initial:
Last Name:
Personal Credentials:
Professional Credentials:
Firm Name:
Street Address:
City:
State:
Zip:
Telephone w/ ext. if applicable:
Fax:
Email:
I am:
Do you wish to remain anonymous?

Incident Information

Incident Date DD/MM/YYYY:

Incident Narrative (Provide a brief overview of your complaint)

Disclaimer

When submitting a complaint about an organization, you may either provide your name and contact information or submit your complaint anonymously.   Providing your name and contact information enables us 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?

FRESNO: (559) 271-0300
VISALIA: (559) 732-3246