Suggestions or Concerns

We love feedback from our staff!
We encourage you to submit your ideas, suggestions and/or concerns directly to us!  We welcome the opportunity to find ways to improve our services for you!

AMS is also committed to the highest standards of business and clinical practices, and as a part of our compliance program, we strive for continuous improvement in all aspects of our operations. 

We equally encourage you to communicate any concerns you may have in regards to our services, operations, or in relation to the work environments you are placed within.  It is vital for your safety as well as for your patients, to always report any concerns or issues related to patient care to your supervisor.  

To submit your ideas, suggestions, or to report a concern, please click on the link and complete the form provided.  Provide a brief written description.  Your submission will be sent confidentially to an AMS officer.
      
You may also send your suggestions, or concerns in writing to:

About Your Suggestion or Concern

What is the nature of your Report?: * select...Bright IdeaSuggestionConcernFellow Nurse ComplimentFellow Nurse ConcernPatient Care IssueStaffing Ratio IssueSafety IssueClinical Incident/IssueAccident / InjuryExposureMed ErrorPatient/Family ComplaintI Do Not Wish to Return to a FacilityNew Client SuggestionOther (specify below)

If other, please explain:

Please provide a detailed description of your suggestion, idea, concern, incident, or injury: *

If concern, Name of person involved?:

Where (or what unit) did the concern occur?:

Date of the concern?:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050

Time of the concern?:

Name of any witnesses to the concern:

Did this occurrence result in a bad outcome for a patient?:

Yes

No

If you are reporting an injury / accident / exposure, were you seen by a physician at the time of the incident?:

Yes

No

Was an incident / accident report completed?:

Yes

No

(If yes to either of the above, please call our office immediately (24 hrs/day), or have your supervisor notify us if you are unable.

Please fax incident report immediately to our office at 903-597-1779 or Toll fax 888-NURS-FAX or 888-687-7329) Failure to do so, may cause denial of claims by our Worker’s Comp Insurance.

Your Contact Information

First Name of person completing this report: *

Last Name of person completing this report: *

Skill Level: * select...RNLVNCNANPPACRNARRTMASurgical TechPTOTPTACOTARad TechPhlebotomistMTMLTSocial WorkerWOCNEMTParamedicDental HygienistDental AssistantDental OfficeMedical Office/ClericalOther (please specify)

Other Skill:

Facility Name (if applicable):

Your Cell Number:

Your Home Phone number: *

Your Work Phone number:

Your Email address: *

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