| Health and Human Services North Dakota

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Last Name

First Name

Address

City

State

ZIP

Email Address

Telephone Number (include area code)

Name of Resident/Patient

Relationship to Resident/Patient

Name of Facility

Location of Facility

Type of Health Care Facility

Other Type

Describe Complaint or Concern (give as much detail as possible including names, dates, and times)

Describe Action Taken Regarding this Complaint or Concern (if any)

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Health Facility Program Complaint Intake Form