Occupational Therapy Practitioner Complaint Form
To assist you with your complaint, the Minnesota Department of Health asks that you complete this form
and submit it, with your written statement, via U.S. Mail to:
Minnesota Department of Health
Health Occupations Program
P.O. Box 64882
St. Paul, Minnesota 55164-0882
Instructions: Please type or print and handwrite clearly, using blue ink. Sign and mail in your completed forms.
Please provide a brief description of your complaint: Please describe the incident that prompted you to file a complaint. Include in your description the name(s) of the practitioner(s) and the facility/location of the incident(s). If possible please include the names and phone numbers of others who may have witnessed the incident(s) of have additional information regarding the practitioner and/or the incident/ please include copies of any supporting documents you may have. If you need more space, you may include additional pages. Please sign and date each statement of complaint page. Your rights are described under the Tennessen Warning included with this form. Based on the information that you provide an investigation will be conducted.
After an investigation is closed, the investigative data is classified as private data pursuant to Minnesota Statute 13.41. Orders for hearing and specification of a final disciplinary action are public data pursuant to Minnesota Statute 13.41.
The document on this page is provided in PDF format. To fill in PDF files electronically you will need to download a free copy of Adobe Acrobat Reader or Adobe Acrobat Reader for Visually Impaired Readers. Adobe provides a free download for these applications at their website.