Submit Your Complaint Submit Your Complaint Name * Name First First Last Last Address * Address Address Apt #, Suite # Apt #, Suite # City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip/Postal Zip/Postal Email * Best phone # for you * Which phone is it? * Home Work Mobile Facility name * City where facility is located * Resident's name * Resident's name First First Last Last Resident's age * Is the resident alive? * Yes No If No, date of death * Was the resident physically harmed? * Yes No If Yes, name the type of injuries/harm * Resident's relationship to you * Date(s) of incident(s) * Please explain what happened. Provide as many details as possible * * I understand this information will be submitted to the Illinois Department of Public Health and agree to the terms and conditions of this site.* Submit If you are human, leave this field blank.
