Form 0920-1424 Appeals and Complaints

FORM APPROVED
OMB NO. 0920-1424
EXP DATE: 12/31/2026

Appeals and Complaints Form
A person and/or a facility reserves the right to initiate an appeal and/or a complaint based on products
and/or services provided by the U.S. NAC. An appeal and/or complaint can be initiated if a person and/or
facility is dissatisfied with the U.S. NAC’s decisions, services, or representatives.

Facility Information
Indicate whether an Appeal or Complaint:
Facility
Name:
Job Title:
*Submitter's name is optional and can be added along side the job title.

Choose One
Facility
Street
Address:
Today’s
Date:

Appeal or Complaint Information
Date Occurred:
Appeal or Complaint Type:

Time Occurred:

Choose One

Please Describe the Appeal(s) and/or Complaint(s) in Detail:

Public reporting burden: CDC estimates the average public reporting burden for this collection of information as 15 minutes per response,
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and
completing and reviewing the collection information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Review
Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1424).

Documentation

Please provide any documentation that can support your claim. All information will be reviewed, and an
investigation will be conducted. For appeals the facility must provide documentation to support the claim
of appealing the decision.

Please list documentation that supports the Appeal or Complaint:

Submission

All complaints and appeals are to be reported to the NAC Quality Team at [email protected] using this
Appeals and Complaints form within 14 business days of the appeal or complaint (audit, certification
decision, meeting, call, etc.,).

NAC Quality Team
Signature/ Date

For U.S. NAC use ONLY
Appeal and/or
Complaint Number