West Virginia Board of Occupational Therapy

COMPLAINT FORM

        1.Complaint is filed against:

                Name: (first middle last)     Telephone: 
                Address: Street: City:      State:     ZIP: 

        2. Person filing complaint (complainant - You):

                Name: (first middle last)      Telephone: 
                Address:  Street:      City:      State:      ZIP: 

        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:      Telephone: 
                Address:    Street:      City:  State:      ZIP: 
       
                Name:      Telephone: 
                Address:    Street:      City:  State:      ZIP: 

        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?:
           

      optional  Complainant Signature (please fill your complete name and initial):
        First:      Middle:    Last:  
optional     INITIAL: 

        NOTE: Complete separate form for each complaint or complainant.

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