Complaints
Complaints
- Online Consumer Complaint
- Online Employer Complaint
- Online Program Complaint
- VDAP Application/Self-Report

Employer Complaint Form

Please use one form for each person you are reporting. To report on multiple nurses, please enter the details again into a fresh form after submitting the previous complaint.

Facility Details

Facility Name:*

Address:*

City:*

State:*

Zip:*

Phone:*

Director of Nursing:*

Facility Administrator:*

Is/Was the Nurse Employed by this Facility:*

Yes

Employer Details

Employer Name:*

Employer Address:*

Employer City:*

Employer State:*

Employer Zip:*

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:*

Current Status of Employment:*

Start Date of Employment:*

Ex: MM/DD/YYYY

End Date of Employment:

Ex: MM/DD/YYYY

Nurse's Supervisor's Name:*

Nurse's Supervisor's Phone:*

Email:

Invalid value

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?:*

Yes

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:*

Email:

Invalid value

Phone:

Invalid value

Submit Complaint