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  • English (US)
  • Incident & Comment Report

  • Use this form to let Variety Care know about any issue, incident, complaint or comment that you may have regarding your Variety Care Experience.

    For example:

    • to let us know about an experience (good or bad) you had at Variety Care
    • reports of incidents or occurrences of wrongdoing, misconduct, fraud, or HIPAA issues
    • reporting an incident or injury
    • any other concerns or compliments

    If you have any trouble using this form, you can print and mail a paper copy of this form by clicking the language you would like: English or Spanish

  • Your Information

  • I understand that I will not be contacted or be able to get updates on this report if I choose to be ANONYMOUS.

  •  -
  • Location, Time, and Details

    Please skip any section that does not apply.
  •  -  -
    Pick a Date  :
  • Please provide all the details you have, including:

    • A description of what happened;
    • Who was present (staff, visitors or patients);
    • Any specific concerns, complaints or compliments; and
    • Information about previous experiences like this one.
  • After you click "Submit," a confirmation message with a green check mark will appear to indicate your report was received.

  • Should be Empty: