Clinical Laboratory Complaint Form
Use this form to register a complaint against a CLIA certified clinical laboratory. To ensure a thorough investigation, please include as much of the following information as possible in your complaint.
Please provide the name and address of the laboratory.
Please provide the name and address of the laboratory.
Name
Address Line 1
Address Line 2
City, State
Zip Code
Please provide the names of anyone involved or affected.
Please provide the names of anyone involved or affected.
Please provide a description of your concern.
Please provide a description of your concern.
Please provide date(s) and time(s) of the incident.
Please provide date(s) and time(s) of the incident.
Date
Time
1.
1. Date
1. Time
2.
2. Date
2. Time
3.
3. Date
3. Time
4.
4. Date
4. Time
5.
5. Date
5. Time
Please provide any details that may verify the problem.
Please provide any details that may verify the problem.
Please provide any additional documentation that may verify the problem.
Please provide any additional documentation that may verify the problem.
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Would you like to remain anonymous?
Would you like to remain anonymous?
Yes
No
Your name and contact information:
Your name and contact information:
Name
Phone
Email Address
