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    Maryland Department of Health
    Board of Occupational Therapy Practice

    Complaint Form

    Board Use Only
    Date Received _______________
    Complaint No. _______________

    Maryland Board of Occupational Therapy
    Spring Grove Hospital Center
    Bland Bryant Building, 4th Floor
    55 Wade Avenue
    Baltimore, MD 21228
    (410) 402-8560

    Please type or print in black ink.

    TO THE PERSON FILING THE COMPLAINT:

    If there is more than one person making this complaint, please use a separate form for each person.

    1. Full name of complainant
      ____________________________________________________________________ 
    2. Home address
      ____________________________________________________________________ 
    3. Business address
      ____________________________________________________________________
    4. Home telephone number _________________________________________________
    5.  Business telephone number ______________________________________________
    6.  Date of Birth _________________________________________________________
    7.  Name of occupational therapist/occupational therapy assistant ____________________
      ____________________________________________________________________
    8. Employment address of occupational therapist/occupational therapy assistant complained about _______________________________________________________________
      ____________________________________________________________________
    9. Telephone number _____________________________________________________
    10. Were you a patient of this therapist? ________________________________________

      If so, from when to when?________________________________________________
    11. Have you discussed your problem with the therapist about whom you made the complaint?____________________________________________________________

      What was the outcome? _________________________________________________
      ____________________________________________________________________
    12. Date(s) of occurrence(s) complained of ______________________________________
      ____________________________________________________________________
    13. Place(s) of occurrence(s) ________________________________________________
      ____________________________________________________________________
    14. Describe in narrative form, with as much detail as possible, the exact nature of your
      complaint(s) against this therapist (use as many additional sheets as necessary,
      number them and sign each  one at the bottom).
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
    15. State the names, addresses and telephone numbers of any witnesses to the occurrence(s) complained of including any persons who were present at the time 
      of the occurrence(s).
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
    16. State the names, addresses and telephone numbers of any other persons who have knowledge of your complaint and/or the occurrence.
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
    17. Have you registered this complaint with any other person or organization?
      ____________________________________________________________________

      If so, to whom? ________________________________________________________
    18. For what condition were you being treated? __________________________________
      ____________________________________________________________________
    19. Will you consent to the release to this Board or its designated investigating body, 
      reports or records relating to you and to this occurrence from any hospital, related
      institution or therapist including the therapist complained of? ______________________
      ____________________________________________________________________
      ____________________________________________________________________

      If not, why not? ________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________

      IF THE COMPLAINT IS MADE BY A PERSON OTHER THAN THE PATIENT, 
      ACTING IN AN OFFICIAL OR PROFESSIONAL CAPACITY, PLEASE FURNISH THE FOLLOWING ADDITIONAL INFORMATION. ALSO, PLEASE BE SURE TO READ, SIGN AND DATE THE LAST PAGE OF THIS COMPLAINT FORM.
    20. Your official title or designation ____________________________________________
    21. Did you personally investigate the matters set forth in this complaint? _______________
      ____________________________________________________________________
      ____________________________________________________________________
    22. If not, or if others assisted you in the investigation, state the names and titles of the
      person or persons, if any, who investigated or assisted in the investigation of such
      matters. 
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
    23. Do you have any reports or other written communications directed to you with respect 
      to the matters complained of? ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
    24. If so, please attach to this complaint copies of such reports and communications.
    25. Please state any further information regarding this complaint which you wish to
      convey to the Board. ___________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________
      ____________________________________________________________________


    ______________________                           __________________________________
    Date of complaint                                                         Signature of complainant

        I HEREBY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT 
    THE MATTERS AND FACTS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

     

    ______________________                              _____________________________
    Date                                                                             Complainant

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