People's Center Clinics & Services Incident & Complaint Report
The Incident & Complaint Report will take approximately 3 minutes. Use this form for reporting any safety, compliance or patient experience complaints.
1. Date
-
Month
-
Day
Year
Date
2. The incident took place at which People's Center Location:
Cedar-Riverside
Longfellow
Other
3. Which department(s) were involved in the incident?
Medical
Dental
Front Desk/ Call Center
On Clinic's premises
Lobby (1st and 2nd floor)
Employee Space
Walk-in Clinic
Other
4. Choose below which staff member(s) were involved:
Nurse
Medical/ Dental Assistants
Provider
Dental Personnel
Administration & Management
Patient Access Representative
Other
5. If you would like a follow-up to the incident, enter your phone number or email address below:
Submit
Should be Empty: