ASDV has received numerous reports of disrespect and abuse by Government and Private sector persons of Disabled in Service and Prisoner of War Veteran businessman (SDVE) and other disabled Veteran persons, especially when SDVE are seeking to pursue the benefits the U.S. Congress has directed in PL-106.50 and stressed in section 3 of PL 108-183. ASDV views and treats these experiences of "discrimination" as the most serious form of harm to SDVE attempting to pursue their rehabilitation as owners and operators of smaller businesses.

In order to properly respond and to classify these reports, ASDV is establishing a basic format to record these reports for effective follow-up and action.

ASDV is conducting this survey of the emergency care experiences of service disabled veterans. It is especially important that we collect reports where lack of prompt and appropriate care led to the death of the veteran.

Please fill out and submit the form below.

When did the incident occur?

Date or Range of Dates:

Describe the acts of assistance providing the name(s) where possible of the individual(s) involved:

Have efforts been made to resolve any complaint through the internal grievance procedure of the government, organization or institution?
Yes No

If "yes" what was the effort?:

Has this complaint been filed or do you intend to file with another organization or agency or the Department of Justice or any other Federal, State or local civil rights agency or court?
Yes, I have filed
Yes, I intend to file
No, I have not filed and do not intend to file

If "yes":

Agency or Court:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Telephone:
Date Filed:

Is there another agency or court you have filed or intend to file with?
Yes, I have filed
Yes, I intend to file
No, I have not filed and do not intend to file

If "yes":

Agency or Court:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Telephone:
Date Filed:

Additional Comments: