Child Life Certification Commission: Ethics Complaint Form
Name of individual submitting complaint:
*
First Name
Last Name
Email of the individual submitting complaint:
*
example@example.com
Phone number of the individual submitting complaint:
*
Please enter a valid phone number.
I prefer to remain anonymous
*
Please Select
Yes
No
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.
If you selected yes, you would like to remain anonymous, please provide the reason you are requesting anonymity:
Back
Next
Name of the CCLS whose behavior you are reporting:
*
First Name
Last Name
What is your relationship with this individual?:
*
City, State/Province, Country where the CCLS is in practice
*
If known, provide the name of the CCLS's employers:
I have contacted the CCLS's employer regarding this alleged behavior.
*
Yes
No
If you selected Yes to the question above, please attach copies of any correspondence to/from the employer:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Provide date(s) or timeframe that this alleged behavior occurred. Be as specific as possible:
*
Provide location(s) that this alleged behavior occurred. Be as specific as possible:
*
Provide the name(s) and contact information of other witnesses to this alleged behavior:
Back
Next
Describe which Rule(s) were allegedly violated in the Child Life Code of Ethics:
*
Describe the actions or inactions of the CCLS named 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.
Attach any relevant documents that provide evidence that a violation of this Rule was allegedly committed. For example, photos, email, or other physical documentation.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach any relevant documents that provide evidence that a violation of this Rule was allegedly committed. For example, photos, email, or other physical documentation.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach any relevant documents that provide evidence that a violation of this Rule was allegedly committed. For example, photos, email, or other physical documentation.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: