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Anyone with knowledge or concerns about the care of a patient/resident in a licensed healthcare facility may file a complaint with their State Survey Agency. Facility Licensing and Investigation Section (FLIS) is the agency that has regulatory oversight for all the licensed healthcare entities in the state.

You may click this link FLIS Complaint Submission to file a complaint if you are concerned about the health care, treatment, or services that you or another person received or did not receive in the facility. Some reasons for filing a complaint would include abuse, neglect, poor care, not enough staff, unsafe or unsanitary conditions, dietary problems, or mistreatment.

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Employee ID *

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Facility Type *

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Moderna Pfizer Johnson and Johnson *

Number of Moderna Doses Wasted: *

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Expiration Date*

Wastage Reason*

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Number of Pfizer Doses Wasted: *

Lot Number(s) Affected*

Expiration Date*

Wastage Reason*

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Number of Johnson and Johnson Doses Wasted: *

Lot Number(s) Affected*

Expiration Date*

Wastage Reason*

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Steps taken to prevent further wastage*

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Important: Please do not attach any Personally Identifiable Information (PII) in your attachment(s).This includes but is not limited to name, phone number, address, date of birth and medical record number. You can only upload PDF, GIF, PNG, JPG, XLS, XLSX, DOC, DOCX files.

DEPARTMENT OF PUBLIC HEALTH

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