Fillable Complaint Process New Jersey Ofce of the Attorney (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Complaint Process New Jersey Ofce of the Attorney (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Complaint Process
AsaunitoftheDivisionofConsumerAffairs,theNewJerseyBoardofNursing(Board),takesitsresponsibilities
seriously.AcopyofthecomplaintwillbeforwardedtothelicenseewithacoverletterfromtheBoardrequiringadetailed
writtenresponsetotheallegationsinthecomplaint.Oncethatresponsehasbeenreceived,itwillbereviewedanddisposition
mayberecommended.IftheBoardneedsadditionalinformation,thelicenseemayberequiredtoappeartoanswerquestions
concerningthematter.
Pleasebeadvisedthatanyinformationyousupplyonthecomplaintformmaybesubjecttopublicdisclosure.Ifan
investigationintothematterisconducted,theinformationissubjecttopublicdisclosureonlyafterthecompletionofthe
investigation.Youarealsoadvisedthatthecompletedcomplaintformisa“governmentrecord,”whichtheBoardmaybe
obligatedtoprovidetoanyonemakingarequestpursuanttotheOpenPublicRecordsAct(OPRA).
YouarefurtheradvisedthatpursuanttoSection4BofExecutiveOrderNo.26,informationconcerninganyindividual’s
medical,psychiatricorpsychologicalhistory,diagnosis,treatmentorevaluationisnotagovernmentrecordsubjecttopublic
access.
Thedispositionofthemattermaytakeseveralmonths.PleaseunderstandthattheBoardcanonlytakeformalactionifit
ndssufcientbasisthatthelicenseeviolatedStatelawsorregulations.IftheBoarddeterminesthatformalactionisrequired,
thematterisreferredtotheOfceoftheAttorneyGeneral.Inthatcase,formalchargesmaybeledagainstthelicenseeand
thelicenseewillbegivenanopportunitytodefendhimselforherself.Thisprocesscantakeaconsiderableperiodoftime.
Ifthecomplaintinvolvesadisputeoverfees,pleasebeadvisedthattheBoardhaslimitedjurisdictionoverfeescharged
byprofessionals.IftheBoarddeterminesthatthereisinsufcientbasistopursuedisciplinaryaction,butdeterminesthat
thematterinvolvesafeedispute,yourcomplaintmaybereferredtotheAlternativeDisputeResolution(ADR)Unitofthe
DivisionofConsumerAffairs.TheADRisafreemediationservicethatcanbehelpfulinresolvingsuchmatters.
Untilanaldeterminationhasbeenmade,theBoardisnotpermittedtodiscloseinformationregardingthematter.You
willbenotiedinwritingwhenanaldeterminationhasbeenmade.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Complaint Form
Please type or print clearly.
Please be advised that any information you supply on this complaint form may be subject to public disclosure. If an
investigationintothematterisconducted,theinformationissubjecttopublicdisclosureonlyafterthecompletionofthe
investigation.Youarealsoadvisedthatthecompletedcomplaintformisa“governmentrecord,”whichtheBoardmaybe
obligatedtoprovidetoanyonemakingarequestpursuanttotheOpenPublicRecordsAct(OPRA).
YouarefurtheradvisedthatpursuanttoSection4BofExecutiveOrderNo.26,informationconcerninganyindividual’s
medical,psychiatricorpsychologicalhistory,diagnosis,treatmentorevaluationisnotagovernmentrecordsubjecttopublic
access.
ConsumerInformation ComplaintReportedAgainst
Name:_________________________________________ Name:_________________________________________
address:_______________________________________ BusiNessName: _________________________________
City:__________________________________________ address:_______________________________________
state:___________________ ZipCode:______________ City:__________________________________________
HometelepHoNeNumBer:_________________________ state:_______________________ ZipCode:__________
WorktelepHoNeNumBer:___ _____________________ telepHoNeNumBer:______________________________
FaxNumBer: ___________________________________ title:_________________________________________
e-mailaddress:________________________________ liCeNseNumBer(iFkNoWN): _______________________
date: _________________________________________ datesoFtreatmeNt/serviCe:
From:___________________ to:__________________
1. Whatistherelationshipbetweenthecomplainantandtheconsumerorpatient?
Self Spouse
Parent Son/Daughter
Friend Brother/Sister
LegalGuardian Other(pleasespecify)___________________________
2. Pleaseprovidethefollowinginformationabouttheconsumerorpatientifheorsheissomeoneotherthanthecomplainant.
Name:________________________________________________________ Dateofbirth: ____________________
Address:______________________________________________________________________________________
Hometelephonenumber:___________________________ Worktelephonenumber:_________________________
(includeareacode) (includeareacode)
Streetaddress City State ZIPcode
MonthDayYear
(includeareacode)
(includeareacode) (includeareacode)
3. Pleaseprovidethefollowinginformationaboutanyotherpractitionerorlicenseeinvolvedinthematteraboutwhich
youarelingacomplaint.
Name:________________________________________________________________________________________
Title:_________________________________________ Licensenumber:_________________________________
Address:______________________________________________________________________________________
Telephonenumber:________________________________
Name:________________________________________________________________________________________
Title:_________________________________________ Licensenumber:_________________________________
Address:______________________________________________________________________________________
Telephonenumber:________________________________
4. Pleaseprovidethefollowinginformationaboutanyonewhowasawitnesstothematteraboutwhichyouarelinga
complaint.
Name:________________________________________________________________________________________
Address:______________________________________________________________________________________
Daytimetelephonenumber:_______________________ Eveningtelephonenumber:_________________________
Name:________________________________________________________________________________________
Address:______________________________________________________________________________________
Daytimetelephonenumber:_______________________ Eveningtelephonenumber:_________________________
5. Whatisthenatureofthecomplaint?(Please check all that apply and provide any additional comments on a separate
sheet of paper.)
Administrative/Recordkeeping Advertising Fees/BillingPractices
Fraud Incompetence InsuranceFraud
Professional/OccupationalMisconduct SexualMisconduct SubstanceAbuse/Impairment
UnlicensedPractice Brieyexplaintheproblemifitisnotlistedabove:_____________
______________________________________________________
6. Pleasedescribethefactsofyourcomplaintintheorderinwhichtheyhappened.Typeorprintclearly.Youmayuse
additionalsheetsofpaperiftheyareneeded.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(includeareacode) (includeareacode)
(includeareacode)

Streetaddress City State ZIPcode
Streetaddress City State ZIPcode
MonthDayYear
(includeareacode)

Streetaddress City State ZIPcode
Streetaddress City State ZIPcode
(includeareacode) (includeareacode)
Streetaddress City State ZIPcode
7. PleasedescribeanyactiontakentoresolvethismatterpriortocontactingtheBoard.Remembertotypeyourresponse
orprintclearly.Youmayuseadditionalsheetsofpaperiftheyareneeded.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
All complaints must be accompanied by readablecopies (No origiNals) of any complaint-related contracts, bills,
receipts,canceledchecks,correspondenceoranyotherdocumentsyoufeelarerelatedtoyourcomplaint.
8. Icertifythatthestatementsmadebymeinthiscomplaintaretrueandanydocumentsattachedaretruecopies.Iam
awarethatifanystatementsmadebymearewillfullyfalse,Iamsubjecttopunishment.
_____________________________________________ ____________________
Signature* Date
Returnto:
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, NJ 07101
*Thiscerticationmustbesignedbythepersonwhohascompletedthisform.
Rev.4/15
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Complaint Process New Jersey Ofce of the Attorney (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 7 October 2021

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