Secure Transportation Complaint Form

Broomfield Public Health and Environment Secure Transportation Services Complaint Form

Confidentiality Waiver: Any individual bringing a matter of medical competency to Broomfield Public Health and Environment shall waive the right of patient confidentiality as a condition of complaint submission and subsequent investigation.

Name

First Name

Last Name

Phone

What is the name of the Secure Transportation Service?

What date and time did the event(s) of concern happen?

What was the location that the event(s) of concern happened?

Is the problem ongoing?

Yes No

Is the client receiving medical care as a result of the incident(s)?

Yes No

What is the client’s condition now?

Was anyone else involved in the incident(s), such as other staff, volunteers, family, friends, other patients, law enforcement, fire personnel, physicians, or bystanders?

Yes No

Please list who else was involved.

Were there any witnesses to the incident(s)?

Yes No

Who were the witnesses?

Have you taken any actions?

Yes No

What actions have been taken?

Did you speak with anyone from the Secure Transportation Service?

Yes No

Who did you speak with and when?

Has the Secure Transportation Service tried to address the situation?

Yes No

What has been done, if anything?

Are any law enforcement agencies involved?

Yes No

Agency(ies) Name(s)

Do you know if the incidents have happened before?

Yes No

Please explain.

May we contact you again if further questions arise?

Yes No

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