University Hospitals Sussex NHS Foundation Trust complaint form

Name of Complainant

First Last

Complainants Address

Street Address Address Line 2 City County Postcode

Name of Patient (if not the Complainant):

First Last

Patient Address

Street Address Address Line 2 City County Postcode

Patients Date of birth

Patient's Hospital Number (if known)

How would you prefer for us to contact you? (please choose one). Please be aware we cannot guarantee the security of emails.

Telephone

In writing

Please provide a telephone number if this is your preferred contact

Please provide an email address if this is your preferred contact

Please provide a correspondence address if this is your preferred contact

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

The Trust often also ring complainants, please confirm you are happy for us to do this.

Yes

Please give us the date(s) of the incident(s)/event(s) that is/are the source of your complaint

Where did the incident(s)/event(s) that is/are the source of your complaint take place?

Please provide an account of the incident/event that is the source of your complaint; remember to include names of staff, places where things happened etc.

What are the questions/concerns you would like us to answer/investigate?

What outcome are you looking for as a result of making this complaint?

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