WVCBAPP Ethics Complaint Form

WVCBAPP Ethics Complaint Form
This form is to be completed by any person, agency, or organization filing a complaint with the WV Certification Board concerning a certified professional or an applicant for certification.
Complaint Information

Please, note you will NOT remain anonymous to the parties involved.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Agency Information

If applicable
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Respondent Information
Respondent Name

First NameLast Name
Respondent Email
example@example.com
Respondent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Respondent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What credential is held or applied for by the professional (select all that apply):

Other
Does this person hold credentials from another boards i.e., social work, counseling, nursing etc., if so please list:
Explain in detail why you believe the individual (Respondent) named above may have violated the the Code of Ethics. Please describe in as specific detail as possible the facts, circumstances, dates and allegations concerning the complaint. If known, please describe the Ethics Standards that have been violated.
Witnesses

If you know of others who have first-hand knowledge of the alleged offense, please provide the following information about them.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload any documents, materials, voice/video records, or other evidence which support your allegations. Submit all relevant documents that will support the allegation(s) in your complaint. Complaints submitted as hearsay and without appropriate evidence maybe dismissed as unfounded.

Cancelof
I, undersigned, agree with the following statements
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

WVCBAPP Ethics Complaint Form

This form is to be completed by any person, agency, or organization filing a complaint with the WV Certification Board concerning a certified professional or an applicant for certification.

Complaint Information

Agency Information

Respondent Information

Witnesses