OmniSeq, Inc
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Complaint Information
This section will be completed by the reporter/complainant if using the website link.
Please complete as much information as possible. If you would like us to reach out, please notate and give contact information. 

If not a direct, Quality will complete this section.
Date incident occurred *
Please enter the date that the error, and/or  issue actually occurred.
Set to now
Did this incident cause any or potentially cause harm or death to someone? *
Details *
Please describe what happened with as much detail as possible.
How does this event affect patient/client/employee?
How was it detected?

Is this a reporting error? *
Test name
Order ID number(s)
Enter affected accession number of report(s), if known
Client name and account #
Name of client and account #, if known
Reporter's preferred method of communication *
Dependent on choice, enter information below 
Reporter's Last Name
Complainant - person/client/employee lodging the potential complaint 
Can be optional if want to keep anonymous. NOTE: OmniSeq will not be able to give feedback/resolution, if anonymous
Reporter's First Name
As above
Reporter's Street Address
The address may be optional but may be required if it is a reportable event
Reporter's City
As above
Reporter's State
As above
Reporter's zip code
As above
Reporter's Country
As above
Reporter's Phone Number
This information is optional, but please provide it to reach out to complainant by phone.
Reporter's Email Address
This information is optional, but please provide it to reach out to complainant by email.
Thank you for your submission. We will investigate your concern. If you selcted a contact preference, we will respond accordingly.