Complaint Form

Commissaire aux plaintes et à la qualité des services du CIUSSS de l'Estrie – CHUS

Step 1 of 5 - User's Information

First name*

Last name*

Date of birth*

Pronoun used*

She

They

Deceased user

Yes

Hospital card number (if known)

Address*

City*

Postal code*

No email

Phone number*

Cell. number

Step 3 of 5 - Installation or person concerned

Concerned installation*

CHSLD

CLSC

Hospital

Rehab center

Private residence

Other

Name of the installation*

City*

Employee name (if applicable)

Doctor’s name (if applicable)

Step 4 of 5 - Description of incident

Date and time of the incident (if applicable)

Statement of Facts*

Expected results*

Step 5 of 5 - Autorisation et complaint preview

I hereby authorize that the integral copy of this complaint form be sent to the manager concerned (when needed)*

Yes

The physician concerned by the complaint will receive a copy of this form in conformity with article 47 of the Act respecting Health Services and Social Services.

User or complainant confirmation*

By checking this box, I confirm the accuracy of the information provided and confirm the filing of the complaint.

Clicking « Next », you will be able to preview your declaration and may modify it if necessary before submitting it.

Don't fill this field!

* Field is mandatory.

Transmission of data online | Confidentiality

No personal data is permanently stored on our servers.

When you provide your information through the secure forms of an appointment center, the information is sent through an electronic messaging system (e-mail) and may involve confidentiality risks.

The CIUSSS de l'Estrie – CHUS cannot guarantee the confidentiality of information transmitted by e-mail.