Fillable Comment Form City of Cleveland Division of Emergency (City of Cleveland)

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Comment Form City of Cleveland Division of Emergency (City of Cleveland)

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The Comment Form City of Cleveland Division of Emergency (City of Cleveland) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Cleveland

BROWSE CITY OF CLEVELAND (OH) FORMS

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City of Cleveland
Division of Emergency Medical Service
Comment Form
Instructions: Please provide as much information as possible. This form can be filled-in either online or printed then filled-in
by hand. This form can be submitted via mail, email, or fax:
City of Cleveland
Division of Emergency Medical Service
Attn: Office of Professional Standards
1701 Lakeside Ave
Cleveland, Ohio 44114
Email: EMSFeedback@city.cleveland.oh.us
Fax: (216) 623-4599
The following information is being submitted to Cleveland EMS as (select one):
A compliment regarding an interaction with EMS personnel
A complaint regarding an interaction with EMS personnel
Person Submitting the Information:
First Name: Last Name:
Address:
City: State: Zip:
Daytime Phone Number:
Interaction Details:
IF YOU WERE NOT THE PATIENT, PLEASE INDICATE THE PATIENT'S NAME AND PHONE NUMBER:
YOUR RELATIONSHIP TO THE PATIENT: DATE AND TIME OF INTERACTION: AMBULANCE NUMBER:
NAME(S) AND/OR BADGE NUMBER(S) OF EMS PERSONNEL, IF KNOWN
LOCATION OF INTERACTION WITH EMS CREW:
DETAILED DESCRIPTION OF INTERACTION:
If you are filing a complaint, please provide additional information as indicated below:
Convenient time of day for you to be interviewed:
Morning Afternoon Evening
Witness Name/Phone No:
Witness Name/Phone No:
Witness Name/Phone No:
Witness Name/Phone No:
Witness Name/Phone No:
If there were other witnesses to this incident, enter the names and daytime phone numbers of up to five
other person(s) that can verify this complaint:
(Revised 11/2011)
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Comment Form City of Cleveland Division of Emergency (City of Cleveland)

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Completed 12 February 2021

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