ARRA Complaint Form
ARIZONA RADIATION REGULATORY AGENCY
4814 South 40
th
Street
Phoenix, AZ 85040
Phone (602) 255-4845 Fax (602) 437-0705
E-mail: BGoretzki@azrra.gov
arra.az.gov
COMPLAINT FORM
Complaint forms can be emailed, faxed, or
mailed to the Interim Director, Brian Goretzki. Upon receipt of
your complaint, we will determine if your complaint comes under our authority. If it does, we will take
such action as is possible under our statutory authority. If your complaint does not fall under our
authority, we will refer you to the appropriate agency.
Name of Complainant (Person Filing Complaint)
Daytime Telephone #
Evening Telephone #
Address of Complainant (Number, Street)
E-mail Address
Respondent (Person the complaint is against)
Respondent’s Employer
Date & Time of Incident
Place of Incident (Facility/Room/Floor)
Type of Procedure performed at time of incident, if known:
Patient’s Name (if not complainant)
Witness Name and Contact Information
Please describe the incident or reason for the complaint, including as many details as possible. Please include
any documentation you feel would be pertinent to the case. If the complaint entails more than one person,
please make note of each person involved.
Describe specifically and in detail your complaint. Please provide copies of any documents, photos, billing
statements, and/or any evidence you believe would support your complaint. (Continues on back of page)
X-Ray RAM Non-Ionizing Other
