FACILITY COMPLAINT FORM

Facility Complaint Form

*Nurse's First Name:

Nurse's Middle Name:

*Nurse's Last Name:

Nurse's Home Address:

City:

State:

Zip Code:

Nurse's Home Phone:

Nurse's Work Phone:

Nurse's License Number:

Nurse's DEA Number:

Nurse's Date of Birth:

mm/dd/yyyy

*Nurse's Social Security Number:

*Facility's Name:

*Facility Type:

*Facility's Address:

*City:

*State:

*Zip Code:

*Facility's Phone:

*Facility's (HR) Email:

Same as Facility Address:

Nurse's Place of Employment (if different):

Nurse's Employer Address:

City:

State:

Zip Code:

Nurse's Employer Phone:

Nurse's Employer Email:

Contact Person:

*Your First Name:

Your Middle Name:

*Your Last Name:

*Your Position:

*Your Email (may be verified):

*Your Daytime Phone:

*Contact person subpoena should be issued to:

Same as Facility Address:

Contact Address(if different):

City:

State:

Zip Code:

*Description stating the exact nature of your complaint(s) against the nurse:
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Nurse Termination Date:

mm/dd/yyyy

Nurse Suspension Date:

mm/dd/yyyy

Nurse Resignation Date:

mm/dd/yyyy

Nurse Other Employment Status:

*Have you filed this complaint with any other person, organization, law enforcement agency, or regulatory agency?

YesNo

If so, with whom?
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*By typing my full name, I hereby declare and affirm under the penalties of perjury that the matters of facts set forth in the foregoing complaint are true and correct to the best of my knowledge, information, and belief:

*Date:

mm/dd/yyyy

*Do you wish to be notified of the Board's final resolution of this case?

YesNo

Kentucky Board of Nursing

FACILITY COMPLAINT FORM