No Pharmacist Left Alone-Complaint Form No Pharmacist Left Alone-Complaint Form Email * Check here if you want a cop of the claim UFCW filed on your behalf Yes Who is submitting the complaint? I am a UFCW member pharmacist submitting this complaint I am a UFCW representative submitting this complaint. Name * Name First First Last Last Address * Name of Employer * Address of Employer * Date of Incident * Local Union Number * Pharmacist License # (as applicable) Position at Local (as applicable) Tell Us What Happened * Please be as specific as possible by including answers to the following questions. Specifics and details matter. Do not worry about offering too much information. 1. Who did you ask for assistance? 2. When did you ask for assistance? (dae, time, length of time help requested for, how long help stayed for) 3.How long was your shift? How many hours did you work alone in the pharmacy? 4. What happened after you asked for assistance that gives rise to your claim? Do you want to remain anonymous? * Yes No Important Disclosure: It amy be less likely the Board of Pharmacy will investigate your complaint if you choose to remain anonymous. Anonymous complaints are still helpful to the Board of Pharmacy and UFCW because they document compliance problems with the new law. Check box if you understand the statement below: * Yes No Complaints submitted to the Board of Pharmacy are NOT public records and are kept confidential. If the Board of Pharmacy formally launches an investigation then it might become public record. Do you have supporting documentation you would like to submit? If yes, email info@ufcwstatescouncil.org * Yes No If you are human, leave this field blank. Submit
