Subject - State of Ohio EMS
|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |DIVISION OF EMERGENCY MEDICAL SERVICES | |
| | | |
| |COMPLAINT FOR | |
| |EMS, FIRE, OR MEDICAL TRANSPORTATION | |
|COMPLAINT AGAINST: |
|(EMS or Fire service provider or instructor, EMS or Fire Educational Institution, or Medical Transportation Service) |
|SERVICE OR INSTITUTION NAME |SERVICE OR INSTITUTION ID NUMBER |
| | |
|STREET ADDRESS OF SERVICE OR INSTITUTION |CITY |
| | |
|STATE |ZIP CODE |TELEPHONE # |EXT. |
| | | | |
|INDIVIDUAL LAST NAME |FIRST NAME |MI |
| | | |
|STREET ADDRESS |APT |CITY |
| | | |
|STATE |ZIP CODE |TELEPHONE # |EXT. |
| | | | |
|EMS/FIRE CERTIFICATE NUMBER (If known) |LEVEL OF EMS/FIRE CERTIFICATION (If known) |
| | |
|EMS OR FIRE AGENCY - AFFILIATION |
| |
|EMS OR FIRE AGENCY AFFILIATION - STREET ADDRESS |CITY |
| | |
|STATE |ZIP CODE |TELEPHONE # |EXT. |
| | | | |
| |
|NOTICE TO COMPLAINANT: |
|Pursuant to the Ohio Administrative Code (O.A.C.), the Ohio Department of Public Safety, Division of Emergency Medical Services may investigate alleged violations|
|of Chapters 4765 and 4766 of the Ohio Revised Code and the rules promulgated thereunder. Please note that if your complaint is determined not to be a violation |
|of Chapter 4765 or 4766, it may be forwarded to the appropriate agency. |
|COMPLAINT FILED BY: |
|In accordance with the O.A.C., Chapters 4765 and 4766, EMS, Fire, and Medical Transportation complaints may be filed anonymously. Please note that the Division of|
|EMS cannot provide a response to you regarding disposition of your complaint without contact information. |
|LAST NAME |FIRST NAME |MI |
| | | |
|STREET ADDRESS |APT |CITY |
| | | |
|STATE |COUNTY |ZIP CODE |TELEPHONE # |EXT. |
| | | | | |
|LEVEL OF EMS/FIRE CERTIFICATION (If known) |E-MAIL ADDRESS |
| | |
|EMS AGENCY, FIRE DEPT., INSTITUTION, OR COMPANY (if applicable) |STREET ADDRESS |
| | |
|CITY |COUNTY |STATE |ZIP CODE |
| | | | |
|DESCRIPTION OF COMPLAINT: |
|(Describe the event, conduct, behavior or circumstances that you believe to be improper. Please provide as much detail as possible, to include, but not limited |
|to date, time, and location.) |
| |
|WITNESSES |
|LAST NAME |FIRST NAME |MI |TELEPHONE # |EXT. |
| | | | | |
|ADDRESS |CITY |STATE |ZIP CODE |
| | | | |
|LAST NAME |FIRST NAME |MI |TELEPHONE # |EXT. |
| | | | | |
|ADDRESS |CITY |STATE |ZIP CODE |
| | | | |
|LAST NAME |FIRST NAME |MI |TELEPHONE # |EXT. |
| | | | | |
|ADDRESS |CITY |STATE |ZIP CODE |
| | | | |
|LAST NAME |FIRST NAME |MI |TELEPHONE # |EXT. |
| | | | | |
|ADDRESS |CITY |STATE |ZIP CODE |
| | | | |
|WHAT REMEDY ARE YOU SEEKING? |
| |
| |
|SIGNATURE: |
|By signing this complaint, I attest that all the information provided is true to the best of my knowledge. I also acknowledge that I am willing to provide a |
|sworn statement concerning this complaint. |
|SIGNATURE OF INDIVIDUAL MAKING COMPLAINT |DATE |
|X | |
PLEASE MAIL COMPLETED FORM TO:
OHIO DEPARTMENT OF PUBLIC SAFETY
DIVISION OF EMERGENCY MEDICAL SERVICES
1970 WEST BROAD STREET
P.O. BOX 182073
COLUMBUS, OH 43218-2073
PHONE: (800) 233-0785 or (614) 466-9447
FAX: (614) 466-9461
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