Complaint Form

Board Use Only
Date Received _______________
Complaint No. _______________

Maryland Board of Occupational Therapy
Spring Grove Hospital Center
Benjamin Rush Building
55 Wade Avenue
Baltimore, MD 21228
(410) 402-8560

Please type or print in black ink.

TO THE PERSON FILING THE COMPLAINT:

If there is more than one person making this complaint, please use a separate form for each person.

  1. Full name of complainant
    ____________________________________________________________________ 
  2. Home address
    ____________________________________________________________________ 
  3. Business address
    ____________________________________________________________________
  4. Home telephone number _________________________________________________
  5.  Business telephone number ______________________________________________
  6.  Date of Birth _________________________________________________________
  7.  Name of occupational therapist/occupational therapy assistant ____________________
    ____________________________________________________________________
  8. Employment address of occupational therapist/occupational therapy assistant complained about _______________________________________________________________
    ____________________________________________________________________
  9. Telephone number _____________________________________________________
  10. Were you a patient of this therapist? ________________________________________

    If so, from when to when?________________________________________________
  11. Have you discussed your problem with the therapist about whom you made the complaint?____________________________________________________________

    What was the outcome? _________________________________________________
    ____________________________________________________________________
  12. Date(s) of occurrence(s) complained of ______________________________________
    ____________________________________________________________________
  13. Place(s) of occurrence(s) ________________________________________________
    ____________________________________________________________________
  14. Describe in narrative form, with as much detail as possible, the exact nature of your
    complaint(s) against this therapist (use as many additional sheets as necessary,
    number them and sign each  one at the bottom).
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
  15. State the names, addresses and telephone numbers of any witnesses to the occurrence(s) complained of including any persons who were present at the time 
    of the occurrence(s).
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
  16. State the names, addresses and telephone numbers of any other persons who have knowledge of your complaint and/or the occurrence.
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
  17. Have you registered this complaint with any other person or organization?
    ____________________________________________________________________

    If so, to whom? ________________________________________________________
  18. For what condition were you being treated? __________________________________
    ____________________________________________________________________
  19. Will you consent to the release to this Board or its designated investigating body, 
    reports or records relating to you and to this occurrence from any hospital, related
    institution or therapist including the therapist complained of? ______________________
    ____________________________________________________________________
    ____________________________________________________________________

    If not, why not? ________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________

    IF THE COMPLAINT IS MADE BY A PERSON OTHER THAN THE PATIENT, 
    ACTING IN AN OFFICIAL OR PROFESSIONAL CAPACITY, PLEASE FURNISH THE FOLLOWING ADDITIONAL INFORMATION. ALSO, PLEASE BE SURE TO READ, SIGN AND DATE THE LAST PAGE OF THIS COMPLAINT FORM.
  20. Your official title or designation ____________________________________________
  21. Did you personally investigate the matters set forth in this complaint? _______________
    ____________________________________________________________________
    ____________________________________________________________________
  22. If not, or if others assisted you in the investigation, state the names and titles of the
    person or persons, if any, who investigated or assisted in the investigation of such
    matters. 
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
  23. Do you have any reports or other written communications directed to you with respect 
    to the matters complained of? ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
  24. If so, please attach to this complaint copies of such reports and communications.
  25. Please state any further information regarding this complaint which you wish to
    convey to the Board. ___________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


______________________                           __________________________________
Date of complaint                                                         Signature of complainant

    I HEREBY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT 
THE MATTERS AND FACTS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

 

______________________                              _____________________________
Date                                                                             Complainant

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