Board of Licensed Social Workers
State of Oklahoma
Post Office Box 18817
Oklahoma City, OK 73154
Phone: (405) 521-3712
Fax: (405) 521-3713
3700 Classen Blvd. STE 162
Oklahoma City, OK 73118
www.ok.gov/socialworkers
james.marks@oswb.ok.gov
Report of Alleged Violation
Best time to contact complainant should the need arise:
Complainant Name:
Complainant Mailing Address (Street, City, State, Zip):
Complainant's relationship with the Social Worker:
Complaint Form Revised 07/2016 Page 1
Please furnish all identifying information, including addresses and telephone numbers, for the complainant, witnesses, and the
professional against whom the report is being filed. Please complete all pages of this form. Additional pages or supporting
documentation may be added as necessary. PLEASE PRINT LEGIBLY or TYPE. Forms and attachments may be sent by fax or snail mail.
COMPLAINANT: PERSON FILING REPORT
If Anonymous, Click Here
Complainant Contact Phone Number:
Complainant Email:
Signature of Complainant: __________________________________________________________
RESPONDENT: PERSON AGAINST WHOM THE COMPLAINT IS BEING FILED
Social Worker's Name:
Licensure Level of the Social Worker, (if known); e.g., LCSW, LSW-ADM, LSW, LMSW, LSWA:
License Number of the Social Worker, (if known):
Social Worker Address (Street, City, State, Zip), if known:
Social Worker Contact Phone (if known):
Social Worker Email Address (if known):
Social Worker's Place of Employment (if known):
Complaint Narrative: DESCRIBE
THE NATURE OF THE
COMPLAINT IN THIS SECTION.
USE SECTION ON PAGE TWO IF
THIS SECTION IS FILLED TO
CAPACITY.
