WVCBAPP Ethics Complaint Form
This form is to be completed by any person, agency, or organization filing a complaint with the WV Certification Board concerning a certified professional or an applicant for certification.
Complaint Information
Please, note you will NOT remain anonymous to the parties involved.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Agency Information
If applicable
Agency Name
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Phone Number
Please enter a valid phone number.
Respondent Information
Respondent Name
*
First Name
Last Name
Respondent Email
example@example.com
Respondent Phone Number
Please enter a valid phone number.
Respondent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What credential is held or applied for by the professional (select all that apply):
*
PRSS-MH
PRSS-SUD
ADC
AADC
CS
CCJP
CSPRSS
CSPRSS-CL
PSI
PS2
Unknown
Other
Does this person hold credentials from another boards i.e., social work, counseling, nursing etc., if so please list:
Explain in detail why you believe the individual (Respondent) named above may have violated the the Code of Ethics. Please describe in as specific detail as possible the facts, circumstances, dates and allegations concerning the complaint. If known, please describe the Ethics Standards that have been violated.
*
Witnesses
If you know of others who have first-hand knowledge of the alleged offense, please provide the following information about them.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Upload any documents, materials, voice/video records, or other evidence which support your allegations. Submit all relevant documents that will support the allegation(s) in your complaint. Complaints submitted as hearsay and without appropriate evidence maybe dismissed as unfounded.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I, undersigned, agree with the following statements
*
I affirm that the facts set forth in this complaint are true and correct to the best of my knowledge and belief.
I understand that the person against whom the complaint is being filed will be informed of this formal complaint process, will be given a copy of the complaint and supporting documentation, and will be given the opportunity to submit rebuttal information and/or materials concerning the complaint.
In filing an Ethics Complaint, the Certification Board President may, at their discretion, proceed with an investigation even if the complainant requests that the complaint be withdrawn.
I am willing to participate in a full investigation of all allegations noted in the complaint.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: