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Lincoln County Ambulance Service Concern Form

  1. Do you request to remain anonymous?
  2. Relationship to you
  3. Base of complaint
  4. Is the problem ongoing?
  5. Is the patient still receiving care as a result of the incident(s)?
  6. Was anyone else involved in the indident(s), such as other staff, volunteers, family, friends, other patients, law enforcement, fire personnel, physicians, or bystanders?
  7. Were there any witnesses to the incident(s)?
  8. Have you taken any actions?
  9. Has the ambulance service tried to address the situation?
  10. Are any law enforcement agencies involved?
  11. May we contact you again if further questions arise?
  12. Leave This Blank:

  13. This field is not part of the form submission.