Online Complaint Form | Nelson County EMS

Nelson County EMS
Compliment / Complaint Form

The following information is being submitted to Nelson County EMS as (select one):

Compliment

Complaint

Other

Person Submitting the Information:

First Name:

Last Name:

Address:

City:

Daytime Phone Number:

State:

Zip:

Email:

Do you request to be contacted?

Yes

Interaction Details:

If you are not the patient, please indicate the patients name and phone number:

Your relationship to the patient:

Date & Time of the interaction:

EMS Squad #:

Location of the interaction with the EMS crew:

Name(s) & or badge number(s) of the personnel, if know:

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

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:

Witness Name/Phone #:

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Caring is Our Profession

Emergency Dial: 911

Office: (502) 348-4929

Nelson County EMS
Compliment / Complaint Form

Person Submitting the Information:

Interaction Details:

IF you are filing a complaint, please provide additional information as indicated below:

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:

1301 Atkinson Hill Ave
Bardstown, Kentucky 40004

Office:
(502) 348-4929

Caring is Our Profession

Emergency Dial: 911

Office: (502) 348-4929​​​

Nelson County EMS Compliment / Complaint Form

Person Submitting the Information:

Interaction Details:

IF you are filing a complaint, please provide additional information as indicated below:

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:

1301 Atkinson Hill Ave Bardstown, Kentucky 40004

Office: (502) 348-4929

Office: (502) 348-4929

Nelson County EMS
Compliment / Complaint Form

1301 Atkinson Hill Ave
Bardstown, Kentucky 40004

Office:
(502) 348-4929