Compliment/Complaint Form

Tabernacle Rescue Squad Compliment or Complaint Form

Tabernacle Rescue Squad welcomes your input on services provided by our personnel. If you had a great experience or our service did not meet your expectations, we want to hear about it.

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This field is for validation purposes and should be left unchanged.
What type of feedback are you leaving?*
- Compliment
- Complaint
Personnel involved**
Please provide names, descriptions and/or vehicle numbers
Incident Date*
Month
Day
Year
Incident Time*

: Hours

Minutes

AM/PM
Incident Address/Location:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Summary of incident*
Describe event, conduct, behavior or circumstances that you believe to be improper. Please provide as much detail as possible,
Name*
First Last
Phone*
Email*
Are you submitting this on behalf of someone else?*
- Yes
- No
Consent*
By submitting this form, I certify that the information I have provided is true and accurate to the best of my knowledge.

I understand that the Tabernacle Rescue Squad will treat the information submitted through this form as confidential and will safeguard personal, medical, and other sensitive information in accordance with applicable federal and New Jersey laws, including the Health Insurance Portability and Accountability Act (HIPAA), when applicable.

Information provided through this form will be used for the review, investigation, and appropriate follow-up of the compliment or complaint. Personal identifying information, protected health information, and other information protected from public disclosure will not be released except as permitted or required by law.

I understand that submission of this form does not constitute consent for the public release of my personal or protected health information.
By checking this box, I acknowledge that I have read, understand, and agree to the acknowledgment and privacy statement above.
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PROUDLY SERVING SHAMONG, TABERNACLE & SURROUNDING COMMUNITIES

Tabernacle Rescue Squad Compliment or Complaint Form