Complaint Form - Service Quality and Complaints Commissioner

Before submitting a complaint, we suggest that you discuss the problem with the caregiver concerned or his/her superior. You can also submit a complaint by E-mail : commissaire.cisssmc16@ssss.gouv.qc.ca

The information submitted is CONFIDENTIAL.

Complaint Form

Si vous êtes un humain, ne remplissez pas ce champ.

Step 1 of 4 - Identification of the User

User's First Name *

User's Last Name *

Address (Number, Street, Appartment) *

City *

Postal Code *

Phone (Home) *

Phone (Other)

Location Concerned (Hospital, CLSC, CHSLD, others)

Location Concerned (Hôpital Charles-Le Moyne, Hôpital du Haut-Richelieu, CLSC (please, specify the site), CHSLD (please, specifiy the site), others.

Room number

User's Record Number

Date of Birth *

Step 2 of 4 - Identification of the legal representative (if applicable)

Complete this section only if the complaint is not lodged by the user.

Legal Representative's First Name

Legal Representative's Last Name

Address (Number, Street, Appartment)

City

Postal Code

Phone (Home)

Phone (Other)

Relationship to the user

Step 3 of 4 - The Complaint – Statement of the Facts

Description - The Complaint

Step 4 of 4 - User’s expectations

Description - Expectations [if description]

You can attach documents to your complaint.

Taille de téléchargement maximum : 10 Mo

I would like to receive the conclusions by e-mail

Your e-mail address

You can reach the Service Quality and Complaints Commissioner by phone : 450 466-5434 or 1 866 967-4825, ext. 8884

i-Centre

Complaint Form – Service Quality and Complaints Commissioner

Step 1 of 4 - Identification of the User

Step 2 of 4 - Identification of the legal representative (if applicable)

Step 3 of 4 - The Complaint – Statement of the Facts

Step 4 of 4 - User’s expectations