Confidential Complaint to Disability Rights Arkansas

All fields below are optional. However, the more information that is provided, the better we are able to investigate concerns.

Name

First Name Last Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Name of Facility/Provider

Your relationship to the facility

Former resident Current staff member Former staff member Parent of resident Guardian of resident Other

Timeframe (the period of time you are referencing or during which you have knowledge of the facility) (Fill in the blanks.) beginning date through ending date .

Concerns are related to (check all that apply):

Please indicate if you have reported this information to anyone else:

Supervisor Facility Director/CEO PRLU (State Licensing) Office of Long Term Care (OLTC) Other

Complaints or Concerns

Please include as many details as you can, including names, dates, and times as possible. If you would prefer to be contacted by DRA staff to confidentially discuss your concerns, please indicate that in the box.

If you have any supporting documents that you would like to provide, you may upload them here:

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Do you wish to be contacted by DRA? (If so, please be sure you have included a phone number or email above before submitting.)

Yes, please contact me. No, please do not contact me.