1. Complaint is filed against*
Name: (first middle last)*
2. Person filing complaint (complainant - You)
Name: (first middle last)
3. Complainant's relationship with the person against whom complaint is being filed*
(e.g. supervisor, co-worker, patient, etc.)
4. Summary of complaint (in your own words: who, what, where, when, why and how)*
5. Other persons with knowledge of incident giving rise to this complaint
6. State in your own words how this incident(s) relates to the WVBOT jurisdiction
7. Have you advised any other regulatory authority of this complaint (explain)?
8. What action, if any, are you seeking from the Board?
Complainant Signature (please fill your complete name and initial)
NOTE: Complete separate form for each complaint or complainant.
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