ASDV

Service Disabled Veteran Emergency Care Report

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 the form below.

Reporting:

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Telephone:

Business Telephone:

Email:

Veteran Requiring Assistance (if other than reporting):

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Telephone:

Business Telephone:

Government, Organization or Institution that was requested to provide assistance:

Name:

Street Address

City

State

Zip

Telephone:

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:

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:

Zip:

Telephone:

Date Filed:

Additional Comments:

See Also:

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