Child Life Certification Commission (CLCC) Ethics Complaint Form
Name of person submitting complaint (required)
I prefer to remain anonymous
*CLCC recognizes that there are situations in which the person filing a complaint may wish to not have their name shared with the person having a complaint filed against. If you would prefer your name not to be shared, please provide an explanation for this request. CLCC will consider this request and contact you to further discuss.
Reason I am requesting anonymity
E-mail of person submitting complaint (required)
Phone Number of person submitting complaint (required)
Name of CCLS whose behavior you are reporting (required):
What is your relationship with this person? (required):
Provide the city and state/province and country where the CCLS is in practice (required):
If known, provide the name of the CCLS's employer:
I have contacted the CCLS's employer regarding this alleged behavior. If you check "yes," please attach copies of any correspondenceto/from the employer.
Provide date(s) or timeframe that this alleged behavior occurred. Be as specific as possible. (required)
Provide location(s) that this alleged behavior occurred. Be as specific as possible. (required)
Provide the names and contact information of other witnesses to this alleged behavior:
Rule(s) allegedly violated (Refer to the Child Life Code of Ethics above) (required)
Describe the actions or inactions of the CCLS named in Section 2 who allegedly violated the Rule(s) noted above. Provide all facts relevant to and providing a context for the issue. Be as specific as possible. (required)
Please list the documents you are attaching that provide evidence that a violation of this Rule was allegedly committed. For example, photos or other physical documentation.
Should be Empty: