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EMS Complaint Form
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Big Spring Fire Department
Emergency Medical Service Complaint Form
Please complete and submit this form. You may also mail this form to Big Spring Fire in a sealed envelope addressed to BSFD, 1401 Apron Dr, Big Spring, TX 79720. If you do not know the information for a particular blank, please leave it empty. You may be contacted at a later date for additional information.
Complainant Information
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Secondary Phone Number
Incident Information:
Date and Time
Date and Time
Date and Time
Address
City
State
Zip Code
Reason for Employee Contact:
Nature of Complaint:
Remedy Sought
Employee Information
Last Name
First Name
Title / Rank
Race
Gender:
Other Involved Employee:
Other Involved Employee
Whitness Information
Witness #1
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Secondary Phone #
Whitness #2
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Secondary Phone #
Witness #3
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Secondary Phone #
Complainant Statement
INSTRUCTIONS: Please describe below in detail the incident about which you wish to complain. Be specific about persons involved and their actions. Use as many pages of the statement form as needed and remember to sign and date the last page.
Statement:
Complaint Made By
NOTE: Complainants signing this government document are swearing and attesting that the information contained herein is true and accurate.
First Name
Last Name
Date
Date
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