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Request an Ambulance

Patient Information

Firstname

Lastname

Gender

Date of Birth

Phone Number

Area

Transport Information

Single Journery

Return Journery

Transport Date

Transport Time

Clinical Information

Requested By

Requester Phone

Patient Condition

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FLLoCA Grievance Redress MechAnism (GRM)

SECTION A: Personal Information (Provision of information in this section is voluntary)

Complainant’s Name

ID Number

Phone Number

Complainant’s Age

Postal Address

Email Address

Sub County

Ward

Village

SECTION B: Complaint Lodge

Which public official/office are you complaining about?

Name/Department/Sub-county/Ward/Agency

Have you reported this matter to any other county official/office? YES/NO

Yes

No

If YES, which one?

Has this matter been the subject of court proceedings? YES/NO

Yes

No

If NO, please give a brief summary of your complaint and attach all supporting documents (Indicate all the particulars of what happened, where it happened, when it happened and by whom)

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Report Corruption

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