Online Report

*Choose Facility where the incident happened:             Choose a facility from list: Fillmore Convalescent Center Lompoc Skilled & Rehab Center Orange Blossom Villa

*Type of Report: Complaint          Praise

*Incident date             (dd/mm/yyyy)   *Approximately at what time?             (hh:mm)AM  PM

*Did you witness the incident? Yes   No

*Did it involve a resident in the facility? No  Yes         If yes, what is the resident's name?

*Did it involve an employee? No   Yes     If yes, what is the employee's name?

Do you know in what department this employee works? Select from the list I don't know Administrator Director of Nurses Assistant Director of Nurses Director of Staff Development Nurse (RN or LVN) CNA or Caregiver Rehab. Dietary / Kitchen Maintenance Housekeeping Laundry Business Office Manager Payroll Clerical (Other Office) Admissions Social Services Activities Medical Records Receptionist

*Please describe the incident: (use as much detail as possible)

Were there other witnesses? No  Yes      If yes, please provide us with their names:

Is there any other information which would be useful for our investigation? Please explain.

You can make this report anonymously, but as part of our investigation we may need to contact you with questions. We guarantee you that we will do everything possible for your report and/or information to remain in a strict confidentiality. (Please refer to our Privacy Policy).

Your name:   

The best phone number to contact you at: (xxx-xxx-xxxx) Home Work  Cell

What is the best time to contact you?   AM          PM

What is your email? Please re-type email

* By checking this box, I hereby certify that all the statements contained in this report are true to the best of my knowledge and belief.  This is a true statement, made under the penalty of perjury.

Without the above box checked the report WILL NOT be accepted