Complaint Form for Emergency Medical Services

NOTE: Complaints may be filed anonymously; however, the Bureau cannot provide a response to you regarding the disposition of your complaint or seek additional information without contact information.

Last Name *

First Name *

Middle Initial

Address *

Apt

City *

State *

Zip *

Phone *

Email *

Please Keep Me Anonymous

YES

Location of Incident *

Date of Incident

Time of Incident *

Incident Address *

Apt

City *

State *

Zip *

Telephone *

EMS Agency/Institution/Education Sponsor

Service/Institution Name *

City *

Service/Institution (If applicable)

City

EMS Provider Information

Individual Provider, Name *

Certification Level (if known)

2nd Provider (if applicable), Name

Certification Level (if known)

Notice to Complainant:

Pursuant to Pennsylvania Consolidated Statutes, Title 35 § 8101 through 8157 known as Emergency Medical Services Systems Act, the Department of Health (Department): Bureau of Emergency Medical Services (Bureau) may investigate alleged violations of the Pennsylvania Consolidated Statutes and the rules promulgated thereunder.

Note: If your complaint is determined not to be a violation of the EMS Systems Act and/or Regulations, it may be forwarded to the appropriate agency for quality review purposes.

Description of Complaint *

What Remedy Are You Seeking? *

By signing this complaint, I attest that all of the information provided is true and correct to the best of my knowledge. I also acknowledge that I am willing to provide a sworn statement and participate in an interview process concerning this complaint.

Name *

Date *

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