Aegis Ombudsman Website

Please complete all sections. Print, Attach and send any additional pages or supporting documents if necessary. If you need assistance in completing this form, please contact the Office of the Ombudsman and we will assist you.


YOUR INFORMATION
Name:
Address:
City:	State: Zip Code:
Daytime Phone:	May we contact you at this number? Yes No
How else may we contact you?
Email Address:

CLINIC OR PROGRAM INFORMATION
Name of clinic / program:
City:
Have you done through other channels about your complaint? Yes No
If yes, please describe your prior attempts to resolve the matter and attach copies of all related paperwork.

Name(s) and phone number of the person(s) you contacted regarding the complaint:


OTHER ASSISTANCE REQUESTED
Have you asked anyone else for assistance? Yes No
If yes, may we talk to that person about your complaint? Yes No
Names and phone numbers:


ADDITIONAL INFORMATION
Please give us any other information we need to help us research your complaint:


COMPLAINT
Use these text boxes to describe your complaint. What occurred?

When did it happen?

Who was involved?

Where did it take place?

How would you like to see this problem resolved?

Send a copy to my email.

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