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Medical Examiners Reporting Form
Please include any information that you feel comfortable sharing. For safety, fill out form on personal computer/device instead of county computers. All reports are confidential.

If you have questions or prefer to report via email, please contact

Date of Issue
Your answer
Describe the Issue / Circumstance of Concern
Your answer
Describe possible remedy or solution you would like to explore
Your answer
Would you like to be contacted?
Preferred Follow-Up
Name (optional)
Your answer
Email (optional)
Your answer
Phone Number (optional; to be used for texting to arrange meeting)
Your answer
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