Home 
About Us 
Links and Resources 
News 
Vaad Reports 
Rate Your Experience 
Voice Your Complaint 
Discrimination Complaint 
Volunteer 
Contact Us 

 

 

 

voice Your complaint

All your information will be forwarded to a Vaad representative who will contact you directly.

Fields marked with an * are required to process your form.

We recommend that you print out a copy of this form after completion but before submission.

* Name:    
* Address:    
* Phone: Fax:
E-mail:    
       
* Patient's Name: Relationship:
* Date Admitted: Date Discharged:
Patients Room & Bed #:
(if patient still hospitalized)
       
* Health Facility: Department:
Physician:    
Date of Occurrence: Time of Occurrence:
Name & Title of the Wrong Doer:
   

*
Nature of Complaint:
Administration  
Medical
Nursing
Food Service
Volunteer Services
Courtesy
Communication
Professionalism
Pastoral/Religious Needs
Housekeeping & Maintenance
 
   
* Details of Complaint:
Response to your complaints (if any):