Adult Care Home Facility Complaint Investigation Form

The Facility Complaint Investigation form is to be used only by KDOA regulated adult care homes in reporting the results of self-investigated allegations of abuse, neglect and/or exploitation.

A report case number must be entered on the form where indicated and can be obtained by contacting the Licensure, Certification and Evaluation Complaint Program at the below number.

Contact Information:

The completed form and accompanying documentation must be sent to the appropriate Regional Manager (see page 6 of the form for contact information) within 5 working days of the Complaint Program's receipt of the initial complaint.

Facility Complaint Investigation Report Form - (CP Form 101 KDOA Revised 03/29/2007)

	Form in Acrobat Reader Format (pdf)
	Form in Word format
	Witness Form
	Witness Form in Word format

The investigation form is made available as an interactive document. The instructions on how to use this interactive form is included under the help button on the form.