"Medical Cannabis Program Complaint and/Or Injury Report Form" - New Mexico

Medical Cannabis Program Complaint and/Or Injury Report Form is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • The latest edition currently provided by the New Mexico Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Department of Health.

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Download "Medical Cannabis Program Complaint and/Or Injury Report Form" - New Mexico

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Medical Cannabis Program
Complaint and/or Injury Report Form
License & Compliance
Today's Date:
Your Full Name:
Your Organization:
Your Title:
Your Phone Number:
Your Email:
I am an MCP (Check all that apply):
☐ Patient
☐ LNPP Grow Employee
☐ LNPP Dispensary Employee
☐ Manufacturer Employee
☐ Laboratory Employee
☐ OTHER:
Who or what is the complaint against (i.e. the name of the person or organization)?
Provide a summary of the nature of the event. Briefly describe who, why, when, where and how the
incident occurred.
Answer the following questions completely and to the best of your ability:
1. Date of occurrence:
Time of occurrence:
2. Date you learned of the issue:
Time you learned of the issue:
3. Where did it occur? Please provide the address and area of location. If the address is unknown,
provide any details you have about the location.
5301 Central Ave. NE • Suite 204 • Albuquerque, New Mexico • 87108
MEDICAL CANNABIS PROGRAM – LICENSE & COMPLIANCE DIVISION
(505) 841-5540 • www.nmhealth.org
Medical Cannabis Program
Complaint and/or Injury Report Form
License & Compliance
Today's Date:
Your Full Name:
Your Organization:
Your Title:
Your Phone Number:
Your Email:
I am an MCP (Check all that apply):
☐ Patient
☐ LNPP Grow Employee
☐ LNPP Dispensary Employee
☐ Manufacturer Employee
☐ Laboratory Employee
☐ OTHER:
Who or what is the complaint against (i.e. the name of the person or organization)?
Provide a summary of the nature of the event. Briefly describe who, why, when, where and how the
incident occurred.
Answer the following questions completely and to the best of your ability:
1. Date of occurrence:
Time of occurrence:
2. Date you learned of the issue:
Time you learned of the issue:
3. Where did it occur? Please provide the address and area of location. If the address is unknown,
provide any details you have about the location.
5301 Central Ave. NE • Suite 204 • Albuquerque, New Mexico • 87108
MEDICAL CANNABIS PROGRAM – LICENSE & COMPLIANCE DIVISION
(505) 841-5540 • www.nmhealth.org
Medical Cannabis Program
Complaint and/or Injury Report Form
4. Who was involved in the complaint? If you do not have names of individuals, provide a description of
the person(s) involved, (e.g. customers, employees, bystanders, friends, family).
5. Describe how you were made aware of the situation. Were you a witness? Did someone tell you
about it? If you were not present, how did you obtain knowledge of the situation?
6. What evidence do you have (e.g. photos, written reports, video/audio recording, eye witness
affidavits)? Please submit any evidence with this report. If no evidence, state “no evidence.”
7. Who else might have knowledge of this event? List their names and contact information, if
applicable.
8. Was anyone hurt?
☐ YES
☐ NO
IF yes, who and to what extreme? List all names and any injuries you are aware of.
a. Were police dispatched to the scene?
☐ YES
☐ NO
b. Was an ambulance dispatched to the scene?
☐ YES
☐ NO
c. Were firefighters dispatched to the scene?
☐ YES
☐ NO
d. Was anyone transported by emergency personnel to a medical facility? If so, who?
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Medical Cannabis Program
Complaint and/or Injury Report Form
9. Have any other agencies been notified? If so, which ones (e.g. OSHA, DPS, Worker’s Comp)?
10. Was an “OSHA 300 Log” filled out or was the incident documented anywhere? If so, where was it
documented?
11. How has the event impacted the business or individual?
12. Were the impacted individual(s) under the influence or inebriated, by any legal or illegal substance?
If so, how do you know?
13. Has there been any damage to people, business, equipment? If so, explain.
14. Is there currently a hazard or threat? If so, explain
15. Was this an isolated incident or a continuing activity?
16. Provide any additional details about the event that you would like to share:
Send questions or submit this form to:
Angie.Cormier@state.nm.us
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