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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) PAGE 1 OF 2 PSC Graphics (301) 443-1090 EF 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) PAGE 2 OF 2