CPR Complaint Form
CPR is committed to listening to client complaints and responding in a fair, timely, and respectful manner. All complaints will be given due consideration without reprisal or bias. Language support for non-English speaking clients will be provided and assistance will be provided for persons with disabilities to file their complaints and seek resolution. All aspects of a complaint will be handled in confidence. However, if the complaint involves allegations of illegal or unethical behavior, information may need to be shared with external authorities. All reasonable attempts are made to resolve complaints within 10 business days and no later than 60 days.
Process
This form will be allocated to the appropriate supervisor who will review the complaint with the provider and complainant to determine a resolution. If a solution cannot be found between the provider, complainant, and supervisor, other CPR leadership, including the Quality Management department, may become involved. The outcome of the complaint will be communicated to the complainant and all involved parties in a timely fashion.
Client Name:
First Name
Last Name
Department
SMI
Hospital Rapid Response
Public Safety Medication Management
Public Safety Counseling
Admin/Support Staff
Transitional Care Department
Other
Filed By:
Filed By's Email Address
example@example.com
Relation:
***Please include specifics such as dates, who was involved, what happened, and where the complaint took place for each section***
Description of Complaint:
CPR Department/Staff Involved in Complaint (if applicable)
Client's Desired Solution:
May we contact the client to discuss?
Yes
No
If yes, please provide preferred contact information.
***FOR CPR STAFF TO COMPLETE**
Steps Taken by Client and Staff:
Resolution Outcome:
CPR Staff's Legal Name
*
First Name
Last Name
CPR Staff's CPR Email Address
*
example@cprecovery.com
Status
*
Completed
Signature:
*
Submit
Should be Empty: