State of Ohio Board of Pharmacy Complaint Form

Per section 4729.23 of the Ohio Revised Code, the identity of an individual submitting a complaint to the State of Ohio Board of Pharmacy is confidential. If, however, after review of the issues in the complaint the Board discovers jurisdiction is more appropriate with a different investigative body, the complaint information may be shared with another agency. Any agency receiving information from the Board is subject to the same confidentiality requirements.

Items marked with a * are required.

Name of Complainant*

Address*

City*

State*

Zip Code*

Home Phone*

Business Phone

Email Address*

Re-enter Email*

Incident Date*

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Is your complaint against a business such as a pharmacy or hospital?*

Yes

No

Name of Business*

Type of Business

Address

City*

State*

Zip Code

Phone Number

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Is your complaint against a person, such as a pharmacist, pharmacy technician, patient or prescriber?*

Yes

No

Name of Individual*

Individual’s Role (pharmacist, pharmacy technician, patient, prescriber, etc.)*

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Does your complaint involve a specific prescription?*

Yes

No

Prescriber Information

Name*

Address

City*

State*

Zip Code

Phone Number

Pharmacy Information

Pharmacy Name

Pharmacy Address

Pharmacy City

Pharmacy State

Pharmacy Zip Code

Patient Information

Name*

Date of Birth*

Prescription Information

Drug Name*

Rx Number

Date Filled

Other information from label

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Does your complaint involve an OARRS report?*

Yes

No

Report # (found below the patient’s name on first page)

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Have you made a complaint to any other government agency, professional association, etc. about this matter?*

Yes

No

Please provide their names and addresses.*

Maximum 8000 characters

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In your own words, with as much detail as possible, please state your complaint.*

Maximum 8000 characters

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Were there any other witnesses or other persons who may have additional information about your complaint?*

Yes

No

Please provide their names, addresses and telephone numbers.*