Step 1 of 3 33% Name(Required) Date(Required) MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone 1(Required)Phone 2Email(Required) Birth Date MM slash DD slash YYYY Nature of ComplaintWere you injured?(Required) Yes No Where on your body?Was equipment being used?(Required) Yes No Can you describe it?Do you have Witness(es)(Required) 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?(Required) 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?(Required) Yes No When? MM slash DD slash YYYY Other comments:Would you like to be contacted with information regarding the resolution of this complaint?(Required) Yes No EmailThis field is for validation purposes and should be left unchanged. Δ
