Provider Type:[radio* ProviderType use_label_element default:1 "NH" "RCF" "RF2"]
Complainant (if other than resident)
Relationship to Client:
Date of Birth:
Verbal Consent to Investigate: YesNo
Verbal Consent to Reveal Identity: YesNo
Complaint as presented by the complainant or resident.
Who presented the above complaint? ComplainantResident
Prior actions taken by complainant or resident to resolve complaint.
Who took prior the prior actions? ComplainantResident
Desired outcome as presented by complainant or resident.
Who presented the desired outcome? ComplainantResident
Action taken by the volunteer (steps taken to investigate and report to appropriate staff):