Clinical Complaint Form

You worked hard for your license, do not risk losing it due to unsafe working conditions. If you have complaints about your clinical environment, please fill out this form. Please note than in order to resolve your clinical concerns, your complaint will be shared with the facility involved.
Name(Required)

Complaint Information

Include all details related to the complaint, including but not limited to names, positions, times, etc. If Law Enforcement was contacted please include the name of the agency and contact person.
MM slash DD slash YYYY
Facility Address(Required)
Acknowledgement(Required)
Name(Required)
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Clinical Complaint Form.