Complaint Form

Take the first step in protecting your own rights. Once your complaint is recorded with the appropriate people, NCDHH can better advocate on your behalf to ensure an issue is resolved to your satisfaction.

If you file a complaint with an organization other than NCDHH, keep careful records so that, if necessary, an NCDHH field representative can assist you as quickly as possible.
Use this form to submit a complaint to NCDHH about a company, organization, or issues.

The information you provide is for confidential use by authorized NCDHH personnel only. By sending this form, you agree the information you provide is accurate and complete to the best of your abilities.

Entries marked with an * is required information.

Contact information from the person submitting the form.

First Name:*

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

E-Mail Address:

Phone Number:* Voice TTY VP

Situation Details

Contact person (or company name) involved in your complaint

Person's Name:

Company/Agency Name:*

Date(s) Occurred:*

Describe the situation. What happened? *
Include location, witness names, and any information describing why you’re filing a complaint. If you have filed a complaint with another agency regarding this same situation, please include that information also.