Florida Certification Board

Florida Certification Board

Ethical Complaint Form
Fill out this form to report an ethical concern.

Before you begin, gather the information you’ll need. This includes any identifying details about the person you’re reporting, a clear description of what happened, any documents you want to upload, and signed releases if you are sharing confidential information.

If you do not have signed releases, make sure to remove or block out all confidential information before submitting.

Complainant (Reporter) Information

The person filing the complaint.
Full Name*

PrefixFirst NameMiddle Name/InitialLast NameSuffix
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Areyou submitting this complaint yourself or on behalf of an employer?

MyselfAn Employer
Agency Name

Detailed Description of the Complaint and Supporting Evidence
Please provide your detailed account in the box below.*
Include the specific date(s) of the alleged conduct and any relevant details such as who was involved, what occurred, where it happened, and when it took place.
Do you have supporting documentation?*

YesNo
Does the documentation contain confidential information protected by HIPAA or another confidentiality law? (Confidential information includes health records, identifying information, or other materials protected by law.)*

YesNo
Do you have signed releases to share confidential information with the Board?*

YesNo
Please Stop Here and Do Not Submit the Form Until Releases are Secured or Confidential Information is Redacted.
Upload Release Forms.*

If your documentation contains confidential information, you must upload an Authorization to Release Information Form or Redacted Confidential/Identifying Information.
Cancelof
Upload supporting documentation: If you do not have signed releases, make sure to remove or block out all confidential information before uploading supporting documents.

You may upload files such as reports, emails, or photos.
Cancelof

Other Individuals to Contact

Witnesses or Others Who Can Provide Information
Please provide the contact information of any other person(s) who may have information relevant to this complaint. The Florida Certification Board (FCB) may contact these individuals as part of the investigation.

You are getting ready to submit an ethical complaint to the FCB. Before you submit it, make sure you have included all available information, any documents with confidential information removed or covered, and the names of anyone else who may have helpful information.

The Board will review your complaint and will contact you within 10 days to let you know whether it has been accepted for investigation, denied, or if more information is needed. The person you are reporting will only be notified if the Board decides to move forward with an investigation.

When you are ready, please sign, date, and submit the complaint electronically.
Signature*

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Complainant (Reporter) Information