CPR Complaint Form
Client Name:
First Name
Last Name
Department
SMI
Hospital Rapid Response
Public Safety
Community Public Safety
Outpatient Counseling
Outpatient Medication Management
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: