West Virginia Board of Occupational Therapy

1. Complaint is filed against*

Name: (first middle last)*

Address

City

State Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Phone Number

2. Person filing complaint (complainant - You)

Name: (first middle last)

Address

City

State Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Phone Number

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

Name: (first middle last)

Address

City

State Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Phone Number

Name: (first middle last)

Address

City

State Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Phone Number

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)

First Middle Last Initial