CONSUMER COMPLAINT FORM

Consumer 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 Date of Birth:

mm/dd/yyyy

*Nurse's Place of Employment:

Nurse's Employer Address:

City:

State:

Zip Code:

Nurse's Employer Phone:

Contact Person:

Nurse's Employer Email:

*Your First Name:

Your Middle Name:

*Your Last Name:

*Your Home Address:

*City:

*State:

*Zip Code:

*Your Email (may be verified):

*Your Day Phone:

Your Work Phone:

*Were you a patient of this nurse?

YesNo

If so, during what period of time?

*Description stating the exact nature of your complaint(s) against the nurse:
Copy Paste is disabled and only special characters allowed for this field are $ % # & ( ) . , ' : " @

*Were there any witness(es)?

YesNo

Contact information of the witness(es) to the occurence(s):
Copy Paste is disabled and only special characters allowed for this field are $ % # & ( ) . , ' : " @

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

YesNo

If so, with whom?
Copy Paste is disabled and only special characters allowed for this field are $ % # & ( ) . , ' : " @

*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

CONSUMER COMPLAINT FORM