Facility Details
 
* Facility Name :
* Address :
* City :
* State :
* Zip :
* Phone :
* Director of Nursing :
* Facility Administrator :
* Is/Was the Nurse Employed by this Facility:
* Your Name :
* Your Title :
Nurse's Details
* Nurse's License # :
* Nurse's Name :
* Nurse's Job Title :
*  Nurse's Phone :
*  Nurse's Address :
*  City :
*  State :
*  Zip :
* Start Date of Employment :
 Ex: MM/DD/YYYY
End Date of Employment :
 Ex: MM/DD/YYYY
* Current Status of Employment :
* Nurse's Supervisior's Name :
* Nurse's Supervisor's Phone :
Email :
Complaint Details
* Where did the Offense Occur? :
Date(s) of Occurrence :
 Ex: MM/DD/YYYY
* Complaint (including what, when, and where) :
* Did the nurse exhibit any physical traits or characteristics that are consistent with chemical impairment?If yes, please explain below.
Witness Details (if any, including Name, Address, and Phone) :
Subpoenas
Note : Please identify the name and address of the person who should receive a subpoena from us :
* Name :
* Title :
* Address :
* City :
* State :
* Zip :
Phone :
Email :
 

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