Pharmacy
REPORT OF CONTACT
NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.
IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)
VA OFFICE
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)
DATE OF CONTACT
06/10/2013
Smith, Brian Tyrus
TELEPHONE NO. OF VETERAN (Include Area Code)
ADDRESS OF VETERAN
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
(615) 573-8424
TYPE OF CONTACT (check one)
PERSON CONTACTED
PERSONAL
Latasha Keyes
TELEPHONE
TELEPHONE NO. OF PERSON CONTACTED
(Include Area Code)
ADDRESS OF PERSON CONTACTED
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
TYPE OF CONTACT (check one)
PERSON WHO CONTACTED YOU
PERSONAL
ADDRESS OF PERSON WHO CONTACTED YOU
TELEPHONE
TELEPHONE NO. OF PERSON WHO
CONTACTED YOU (Include area code)
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed)
On 6/10/2013 I was instructed by my Supervisor (LaTAsha Keyes) to locate my co worker
Irvin Ausama,because there was a tasked she needed myself,Erroll Black and Mr. Ausama to complete as wwe were walking to go and get Mr. Ausama we ran into Another
Supervisor Mr. Dimacali and asked him if he knew where Irvin was assigned he stated that he was in the Pharmacy so Mr.Black and I approached the Pharmacy and rang the door bell. A lady approached the door and asked us what we were there for, we stated that we were looking for employee Irvin Ausama, she then asked for us to standby
DIVISION OR SECTION
VA FORM
SEP 1997 (R)
119
EXECUTED BY (Signature and title)
AdobeFormsDesigner
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN
NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.
IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)
VA OFFICE
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)
DATE OF CONTACT
06/10/2013
Smith, Brian Tyrus
TELEPHONE NO. OF VETERAN (Include Area Code)
ADDRESS OF VETERAN
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
(615) 573-8424
TYPE OF CONTACT (check one)
PERSON CONTACTED
PERSONAL
Latasha Keyes
TELEPHONE
TELEPHONE NO. OF PERSON CONTACTED
(Include Area Code)
ADDRESS OF PERSON CONTACTED
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
TYPE OF CONTACT (check one)
PERSON WHO CONTACTED YOU
PERSONAL
ADDRESS OF PERSON WHO CONTACTED YOU
TELEPHONE
TELEPHONE NO. OF PERSON WHO
CONTACTED YOU (Include area code)
VA Southern Nevada Health Care Systems
6900 North Pecos Road Building 1
North Las Vegas, Nevada 89030
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed)
On 6/10/2013 I was instructed by my Supervisor (LaTAsha Keyes) to locate my co worker
Irvin Ausama,because there was a tasked she needed myself,Erroll Black and Mr. Ausama to complete as wwe were walking to go and get Mr. Ausama we ran into Another
Supervisor Mr. Dimacali and asked him if he knew where Irvin was assigned he stated that he was in the Pharmacy so Mr.Black and I approached the Pharmacy and rang the door bell. A lady approached the door and asked us what we were there for, we stated that we were looking for employee Irvin Ausama, she then asked for us to standby
DIVISION OR SECTION
VA FORM
SEP 1997 (R)
119
EXECUTED BY (Signature and title)
AdobeFormsDesigner
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN