Reporting Harm CT Academy of Nutrition and Dietetics Form for Reporting Harm * indicates required field Petitioner/Complaintant Name:* Date of Birth:* Email:* Address:* Home Phone:* Work Phone:* Relationship to patient/complainant: self parent spouse son/daughter other (please explain below) Patient Information Patient's Name: Patient's Address: Patient's Phone Number(s): Patient's Date of Birth: Respondent/Healthcare Provider (Subject of the complaint) Providers Name: Providers Address: Profession/specialty (i.e., registered dietitian, CD-N, chiropractor, naturopath, nurse practitioner, APRN, allergist, physician/cardiology, dentist/general): Providers Phone Number: Nature of Complaint Subject:* Please indicate the nature of your complaint (check one): Quality of Care Unlicensed Practice Unsanitary Conditions Substance Abuse Failure to Release Patient Records Sexual Contact with Patient Insurance Fraud Other (specify below) Concerns Describe your concerns below. Include as many specific details as possible (who, what, when, where, why). Concerns:* Leave this field empty
