B. Information to be obtained about complaint

The following basic information should be obtained and recorded on an SSA-5002, Report of Contact:

1. The name and address of the facility where the incident occurred;

2. The date the incident occurred;

3. The basis for the complaint (race, color, or national origin);

4. The services or facilities about which the complaint is being made (admissions, bed assignment, dual standards for the cost of medical service, dual standards in assignments to or use of hospital facilities, visiting privileges, etc.) including a complete narrative description concerning the nature of the practices alleged to be discriminatory. When possible, names and titles of persons involved should be given.

5. The name, address, and telephone number, if any, of the complainant. This information may be needed to contact the person for more information and to notify the person of the results of the investigation. If the complainant appears to be reluctant to identify himself explain that the information will be kept confidential and will not be released to anyone without the complainant consent. If the individual refuses to give this information, accept the complaint and indicate that the complainant prefers to remain anonymous.

6. If a complaint has been made to the provider or the State health or welfare department, indicate to whom the complaint was made, the date, and the outcome if known.

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B. Information to be obtained about complaint

Official source

The following basic information should be obtained and recorded on an SSA-5002, Report of Contact:

1. The name and address of the facility where the incident occurred;

2. The date the incident occurred;

3. The basis for the complaint (race, color, or national origin);

4. The services or facilities about which the complaint is being made (admissions, bed assignment, dual standards for the cost of medical service, dual standards in assignments to or use of hospital facilities, visiting privileges, etc.) including a complete narrative description concerning the nature of the practices alleged to be discriminatory. When possible, names and titles of persons involved should be given.

5. The name, address, and telephone number, if any, of the complainant. This information may be needed to contact the person for more information and to notify the person of the results of the investigation. If the complainant appears to be reluctant to identify himself explain that the information will be kept confidential and will not be released to anyone without the complainant consent. If the individual refuses to give this information, accept the complaint and indicate that the complainant prefers to remain anonymous.

6. If a complaint has been made to the provider or the State health or welfare department, indicate to whom the complaint was made, the date, and the outcome if known.