Discipline and Complaints - File A Complaint or Self-Report Form

Please complete the form below to the best of your abilities. When finished, click once on the "Submit Complaint" button at the bottom of the page to submit the form for processing.

If you have questions about when to report, see our Complaint Evaluation Tool.

NOTE: You will receive an email confirmation once the form has been successfully submitted.

Please complete all required (*) fields below with your information.


Your Information:
(Optional; however, please note that anonymous complaints can be harder to investigate and that we cannot provide any follow-up information to you if you file the complaint anonymously)
Your First Name:
Your Last Name:
Title:
Agency or Organization:
Address:
City:
State:
Zip Code:
Email Address:
Phone Number/Extension:  

Your Complaint is Against (Licensee):
Please complete as many of the fields below as you can.
Licensee First Name: *
Licensee Last Name: *
License Type:
License # (if known):
How were you made aware of this licensee/certificate holder?
Licensee's Place of Work (Facility): *
Licensee's Work Address:
Licensee's Work Address City:
Licensee's Work Address State:
Licensee's Work Address Zip Code:
Licensee's Supervisor (if known):
Licensee's Supervisor's Phone:
Licensee's Supervisor's Email Address:
Licensee Employment Status (if known):

Complaint Facts: *

Be sure to include as many facts pertaining to the complaint as possible, including: dates, times and locations of incidents; behaviors of respondent which were observed by you; any statements or admissions made by respondent; full names of any witnesses.
Date of Incident: [MM/DD/YYYY] / / *
Location of Incident: *

Patient Information:
The Board is a health professional regulatory agency that is authorized to receive HIPAA protected information without a signed authorization, pursuant to Federal Title 45 CFR ยง 164. To view full language, click here.
Patient's First Name:
Patient's Middle Initial:
Patient's Last Name:
Patient's Date of Birth: [MM/DD/YYYY] / /  
Patient's Medical Record #:
Have you filed this complaint elsewhere (facility, Adult Protective Services, law enforcement)?:  

Supporting Documentation:

Please use the fields below to attach copies of any relevant supporting documents such as patient record including patient name and/or medical record number, incident reports, memos, written statements, narcotic count sheets, Pyxis reports, narcotic audits, urine drug screen results, anecdotal/counseling notes, time cards, pertinent policies and procedures. Alternatively you can email supporting documentation to roberta.poole@osbn.oregon.gov or fax to (971) 673-0683.

NOTE: If your file(s) are larger than 10MB, please fax or email them using the info above.
I would like to be informed regarding the outcome of this complaint:

Verification by Oath or Affirmation:
I verify that the statements are true in every respect; that I have not suppressed any information that would affect this complaint; that I will obey the laws and rules of the Oregon State Board of Nursing; that I have read and understood that failure to disclose the requested information or disclosure of false information or disclosure of misleading information may constitute fraud and may result in criminal prosecution.

By clicking the "SUBMIT COMPLAINT" button, you agree to the above Verification by Oath or Affirmation.

Submitting Complaint. Please wait.

 

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