Form #7 Attachment I: OCR Patient Safety Confidentiality Complai

Form Approved: OMB No. 0935-0143

See OMB Statement on page 2.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office for Civil Rights (OCR)

PATIENT SAFETY CONFIDENTIALITY COMPLAINT
Your First Name

Your Last Name

Home Phone (Please include area code)

Work Phone (Please include area code)

Street Address
State

City
ZIP

E-Mail Address (If available)

Who is the patient, provider or reporter who is identified in the information you believe was impermissibly disclosed?
First Name or Business Name

Last Name (Leave blank if using Business Name to left)

Who (e.g., provider, patient safety organization, other person) do you believe disclosed patient safety work product in violation
of patient safety confidentiality?
Person/Agency/Organization
City

Street Address
State

ZIP

Phone

When do you believe that the impermissible disclosure occurred?
List Date(s)

Describe briefly what happened. How and why do you believe a person or organization impermissibly disclosed patient safety
work product? Please be as specific as possible. Why do you believe the information disclosed is patient safety work product?
(Attach additional pages as needed)

Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email
represents your signature.
Signature

Date (mm/dd/yyyy)

Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed
with your complaint. We collect this information under the Patient Safety and Quality Improvement Act of 2005 (Patient Safety
Act). We use it to investigate your complaint to see whether enforcement action is appropriate. The Privacy Act of 1974
protects the information submitted on this form. We may share your information with the Department of Justice or a court in
the event of a lawsuit, with another agency that has jurisdiction over potential violations or reviews certifications of Patient
Safety Organizations, or with others who help us carry out our work. Otherwise, OCR will not share your name or other
identifying information about you unless you agree. You are not required to use this form. You may write a letter or submit a
complaint electronically with the same information. You will find directions for submitting an electronic complaint on our web
site at http://hhs.gov/ocr/privacy/psa/complaint/index.html. To mail a complaint see reverse page for OCR address.
HHS-758 (11/08)

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PSC Graphics (301) 443-1090

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The remaining information on this form is optional. Failure to answer these voluntary
questions will not affect OCR's decision to process your complaint.
Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)
Braille

Large print

Cassette tape

Computer diskette

Electronic Mail

TDD

Sign language interpreter (Specify language):
Foreign language interpreter (Specify language):
Other (Specify):
To help us better serve you, answer the following question.

HOW DID YOU LEARN ABOUT THE OFFICE FOR CIVIL RIGHTS?
HHS Website / Internet Search
Phone Directory

Family / Friend / Associate

Employer

Conference / OCR Brochure

Religious / Community Org

Fed / State / Local Gov

Lawyer / Legal Org

Healthcare Provider / Health Plan

Other (Specify):

If we cannot reach you directly, is there someone we can contact to help us reach you?
First Name

Last Name

Home Phone (Please include area code)

Work Phone (Please include area code)

Street Address
State

City
ZIP

E-Mail Address (If available)

Have you filed your complaint anywhere else? If so, please provide the following: (Attach additional pages as needed)
Person / Agency / Organization / Court Name(s)
Date(s) Filed

Case Number(s) (If known)

To mail a complaint, please type or print, and return completed complaint to:
Office for Civil Rights
Department of Health and Human Services
Attn: Patient Safety Act
200 Independence Ave., SW, Rm. 509F
Washington, DC 20201
(202) 619-0403
TDD 1-800-537-7697
FAX: (202) 619-3818
To submit an electronic complaint, see our web site at http://hhs.gov/ocr/privacy/psa/complaint/index.html.

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 20 minutes per response,
including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed
complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management,
200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201.
HHS-758 (11/08)

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