Fillable Complaint Report - Wyoming State Board Of Nursing printable pdf download

Wyoming

Matthew H. Mead

Cynthia LaBonde MN, RN

Governor

Executive Director

STATE BOARD OF NURSING

130 Hobbs Avenue, Suite B • Cheyenne, Wyoming 82002 • Phone: 307-777-7601 • FAX: 307-777-3519 •

Complaint Report (Must be typed or printed legibly)

Your name, or the name of the person registering the complaint _______________________________________________________

Address: ____________________________Phone: ____________________Employer Name: ____________________________

Employer Address: ________________________________Employer phone: __________________________________________

Name of person being reported: ____________________________License Type: ____________________

License/Certificate number (if known):_______________________________________Expiration date: ______________________

Employer Name: _______________________________ Employer Address: _____________________________________

Phone: _______________________ Employment position: _____________________________

Employment Dates: ___________ to __________ Current Employment Status: _________________________

Location of incident: ____________________________ Date of incident: _________________Time of Incident: _____________

Specifics of Complaint: Additional information is often needed to complete an investigation; in the space below provide a brief

description of the incident, dates, patient identification, nurse behaviors, and attach documentation supporting your allegation

(i.e., copies of patient records, Medication Administration Records (MARs) and narcotic records, statements of witnesses

and/or persons involved, confession, policies and procedures, employee handbook, staffing schedule, patient assignment,

incident reports, termination notice, name and address of all witnesses). If additional space is required, please use additional

paper.

_____________________________________________________________________________________________________

___________________________________________________________________________________________________

You must sign this form. Per the Administrative Rules & Regulations we cannot accept anonymous complaints. Licensee is

notified and a copy of the complaint is sent to the licensee as part of due process.

_________________________________________________________________________________________________________

Signature of person filing complaint

Title:

Date

Complaint Report - Wyoming State Board Of Nursing