DPH Ticketing System

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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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First name of the submitter: *

Last name of the submitter: *

Contact phone number: *

Phone number extension:

Contact email: *

Employee ID *

Preferred method of communication: *

Phone Email

Is your state CT? *

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Name of organization/provider/local health department *

Case ID

Facility Type *

Facility Name *

Care Partner Name *

CVP PIN #

Clinic Closing/Merging *

Provider PIN # *

Choose muiltiple vaccine types

Moderna Pfizer Johnson and Johnson Novavax *

Number of Moderna Doses Wasted: *

Lot Number(s) Affected*

Moderna NDC #*

Only 1 Moderna NDC can be reported at a time.
If you have multiple wastages for Moderna NDCs, please submit a separate ticket.

Expiration Date*

Wastage Reason*

Other

Number of Pfizer Doses Wasted: *

Lot Number(s) Affected*

Pfizer NDC #*

Only 1 Pfizer NDC can be reported at a time.
If you have multiple wastages for Pfizer NDCs, please submit a separate ticket.

Expiration Date*

Wastage Reason*

Other

Number of Johnson and Johnson Doses Wasted: *

Lot Number(s) Affected*

J&J NDC #*

Only 1 J&J NDC can be reported at a time.
If you have multiple wastages for J&J NDCs, please submit a separate ticket.

Expiration Date*

Wastage Reason*

Other

Number of Novavax Doses Wasted: *

Lot Number(s) Affected*

Novavax NDC #*

Only 1 Novavax NDC can be reported at a time.
If you have multiple wastages for Novavax NDCs, please submit a separate ticket.

Expiration Date*

Wastage Reason*

Other

Steps taken to prevent further wastage*

Please do not include Personal Identifiable Information (PII) in your description.

Brief description of the issue:*

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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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