Step 1 of 3 33% Name* Date* MM slash DD slash YYYY Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone 1*Phone 2Email* Birth Date MM slash DD slash YYYY Nature of ComplaintWere you injured?* Yes No Where on your body?Was equipment being used?* Yes No Can you describe it?Do you have Witness(es)* Yes No Who?Did anything out of the ordinary happen that may have contributed to the complaint?Other possible factors: What could have been done to prevent the complaint?Did you report your complaint to clinic staff right away?* Yes No Why Not?When did you report your complaint to Clinic staff? MM slash DD slash YYYY Have you reported a similar complaint before?* Yes No When? MM slash DD slash YYYY Other comments:Would you like to be contacted with information regarding the resolution of this complaint?* Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged.