Facility Complaint or Concern Form

Submit a complaint or concern related to a QUAD A Accredited Facility.

Thank you for taking the time to share your patient safety concerns or event regarding a QUAD A accredited facility. We take all concerns and complaints about accredited organizations seriously.

Please use this form to report a patient safety event or concern. Please be aware that QUAD A’s evaluation focuses on assessing compliance with our standards and may not be able to assess areas of concern outside the scope of our programs. Some concerns are more appropriately directed to the professional licensing body (e.g. medical, dental, or nursing board) or department of health for the state in which the organization is located.

Location (where the concern or event occurred)

Facility name

Street address*

Street address 2

Country - Select From List*

City*

Postal code*

Your Information

You have the option to submit your safety concern or event anonymously, or you may provide your personal information.

Your identity as the source of this will be kept confidential to the best of our ability unless you allow us to share your name with the organization (see disclaimer).

First name

Middle Name

Last name

Email*

Even if you choose to submit your complaint anonymously, we still need your email address. We use it to confirm that we've received your submission and to contact you if we need additional information. Rest assured, your email address will not be shared with the facility or used for any other purpose.

Disclaimer/Confidentiality Waiver

QUAD A is here to help organizations improve. We will use your report to better understand systems of care and guide improvement.

We will review your report and determine how best to evaluate your concerns. This could include contacting the organization about your concern.

Should we find it necessary to contact the organization about your concern, please confirm whether you give QUAD A permission to release your name as the source of this concern and share a copy of the information you have sent to QUAD A with the organization.

Confidentiality Waiver*

Yes, I give QUAD A permission to share my name as the source of information and share a copy of the information I have sent with the organization.

No, QUAD A may not share my name as source and a copy of the information may not be shared with the organization.

*Disclaimer:

Permission to share may not result in an inquiry, but it will enable sharing your name as source, and a copy of the information should QUAD A decide to write the organization about your
If confidentiality is not waived, we may still act on your reported safety concerns following our established processes for anonymous reporting. Anonymous reporting is no guarantee of confidentiality since the organization could independently investigate and become aware of your identity.
If your submission contains a threat to others, this information may be shared in its entirety, and anonymity will not be maintained.
Please be aware that we cannot provide you with the organization’s response should an inquiry be pursued.

Description of Concern or Event

Date of Occurrence*

Month/Day/Year

Incident Narrative:
Please provide a brief overview of your patient safety concern or event.

Thank you for bringing your concerns to our attention and helping us with our mission of continuously improving healthcare.

Incident Narrative*

Type or Write Narrative Here: