Complaint form

Complaint Form

You may use this form to submit a complaint to our office. The complaint will be forward to a Regional Ombudsman, who will be in contact with you if they need more information.
All information received is Confidential. Your name will not be released without your permission.

Please note: The Office of the Long-term Care Ombudsman is not a first responder. In an emergency, if someone is in immediate danger, please call 911.

Information about the resident

First name

Last name

Facility Name

City

State

Your relationship to the resident

Information about complainant, if different from resident

First

Last

Best phone number to reach you at (including area code)

Does the resident know you are contacting the Ombudsman office for assistance?

Yes
No

If the resident is not aware, do we have your consent for us to let the resident know about your complaint?

Yes
No

Please describe the nature of your concern or complaint.

Thank you for contacting our office; your concern will be provided to a regional ombudsman for follow-up. If you included your contact information, the ombudsman may contact you to seek additional information.

The Ombudsman program’s mandate is to represent the resident and assist at his or her direction. The Older Americans Act (OAA) requires the Ombudsman program to have resident consent before investigating a complaint or referring a complaint to another agency. When someone other than the resident files a complaint, the ombudsman must determine what the resident wants to the extent possible. The identities of other residents, complainants, and witnesses also may not be revealed without their consent.

Therefore, you may ALSO want to refer your complaint directly to the regulatory agency that licenses and regulates long-term care facilities, the Kansas Department for Aging and Disability Services (KDADS). Their phone number is 1-800-842-0078, and their email address is kdads.complainthotline@ks.gov”

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