MISSOURI DEPARTMENT OF SOCIAL SERVICES PO BOX 88 CHILDREN'S DIVISION JEFFERSON CITY, MO 65103 RESIDENTIAL PROGRAM UNIT COMPLAINT SUMMARY
AGENCY:
ADDRESS:
COMPLAINT SOURCE	IDENTIFYING INFORMATION
HOTLINE	INCIDENT#	DATE
OTHER	COMPLAINANT	DATE
INCIDENT OCCURRED	DATE	TIME
ACTION TAKEN (AS REQUIRED)	DATE AND NAME
CONTACT WITH OHI INVESTIGATOR
PHONE/EMAIL CONTACT WITH AGENCY
CRITICAL INCIDENT RECIEVED FROM AGENCY (DATE/TIME)
INTERNAL INVESTIGATION RECEIVED FROM AGENCY
REMINDER LETTER FOR WRITTEN INFORMATION (IF NECESSARY)
OHI SUMMARY RECEIVED
CORRECTIVE ACTION PLAN REQUESTED (IF NECESSARY)
CORRECTIVE ACTION PLAN RECEIVED (IF NECESSARY)
FILED IN RPU SHARE DRIVE
OUTCOME OF HOTLINE
SUMMARY OF COMPLAINT: