Confidential Complaint to Disability Rights Arkansas

Confidential Complaint to Disability Rights Arkansas

Your identity will never be shared with anyone outside of Disability Rights Arkansas without your express permission.
All fields below are optional. However, the more information that is provided, the better we are able to investigate concerns.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name of Facility/Provider
Your relationship to the facility

Former residentCurrent staff memberFormer staff memberParent of residentGuardian of residentOther
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):

AbuseEducational NeglectElopements/Runaways/Missing ResidentsInjuriesMedical NeglectMedication ConcernsMisuse of FundsNeglectOutbreak of a Communicable DiseasePhysical or Sexual AssaultSupervision LevelsTreatment/Lack of TreatmentUse of Restraint or SeclusionUse of Chemical RestraintsOther
Please indicate if you have reported this information to anyone else:

SupervisorFacility Director/CEOPRLU (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:

Cancelof
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.
Should be Empty: