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2. Date and Time
   Date and Time

   Date and Time
3. Do you request to remain anonymous?

   1. Yes
   2. No
5. Name
6. Address
8. Phone
9. Email
11. Patient Name
12. Submitting on behalf of
14. Relationship to you

    1. Self
    2. Peer
    3. Child

    1. Spouse
    2. Parent
    3. Other
16. Base of complaint

    1. Quality of Care
    2. Response Time
    3. Emergency Medical Personnel
18. What is the name of the Ambulance Service, if known?
20. What prompted this complaint? (What happened?)
22. When did the event(s) of the concern happen?
    When did the event(s) of the concern happen?

    When did the event(s) of the concern happen?
24. Is the problem ongoing?

    1. Yes
    2. No
26. Is the patient still receiving care as a result of the incident(s)?

    1. Yes
    2. No
28. What is the patient's condition now?
30. Was anyone else involved in the indident(s), such as other staff, volunteers, family, friends, other patients, law enforcement, fire personnel, physicians, or bystanders?

    1. Yes
    2. No
32. Were there any witnesses to the incident(s)?

    1. Yes
    2. No
34. If there were witnesses, who were they?
36. Have you taken any actions?

    1. Yes
    2. No
38. If so, what actions have been taken?
40. Date and Time
    Date and Time

    Date and Time
42. Has the ambulance service tried to address the situation?

    1. Yes
    2. No
44. If so, what has been done, if anything?
46. Are any law enforcement agencies involved?

    1. Yes
    2. No
48. If so, please explain.
50. May we contact you again if further questions arise?

    1. Yes
    2. No
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field