Online complaint form

* = required fields

User's identification

Person who receives, has received or should have received health care and social services

I am the person who receives health care and services *

Name *

First name *

Date of birth *

Address *

Postal Code *

Email *

City *

Phone number *

Complaint author

If you are not the person who receive or should have received health care and services

I am a witness to this incident and do not receive health care and services *

I am the user's legal representative *

Do you have the user's consent to represent him? *

Does the user know you are filing a complaint on their behalf about this situation? *

The complaint

Choose the installation *

Which department?

Employee's name or their physical description (if applicable)

Job title *

Date of the even/incident *

Describe the subject of your complaint (who, what, where, when, why) and be as specific as possible *

What results are you looking for, your expectations, your questions? *

Authorization to disclose

I authorize the Service Quality and Complaints Commissioner to forward a complete copy of this complaint to the director responsible for the concerned department of my complaint, for the sole purpose of processing it. Confidentiality will be preserved throughout the process of analyzing your complaint.

Yes
No

I authorize the Service Quality and Complaints Commissioner to email me for all written communications

Yes
No

Signature

Signature *

Checking this box will be considered as proof of signature for this complaint form

COVID-19

User's identification

Complaint author

The complaint

Authorization to disclose

Signature