Fillable ETHICS COMPLAINT FORM READ DIRECTIONS CAREFULLY (Pennsylvania Certification Board)

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ETHICS COMPLAINT FORM READ DIRECTIONS CAREFULLY (Pennsylvania Certification Board)

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ETHICS COMPLAINT FORM – READ DIRECTIONS CAREFULLY
This form is to be completed by any person/agency/organization filing a complaint with the PA
Certification Board concerning a certified professional or an applicant for certification.
PART 1
Name of Person Filing Complaint:
Cell Phone:
Email:
Home City:
Agency Name:
Agency City:
Name of the certified professional or applicant for certification against whom the complaint
is being filed:
Name:
Street Address:
Cell Phone:
Email:
Credential(s) held by certified professional, if known:
□ AAC □ CRS □ CPS - prevention
□ CAAC □ CPS – peer □ CCSM
□ CADC □ CFRS □ CCMS
□ CAADC □ CIP
□ CCDP □ CAAP
□ CCDP Diplomate □ CCHW
□ CCJP
□ CCS
Home City:
PCB Ethics Complaint Form | Revised October 2020 2
PART 2
Please describe in as specific detail as possible the facts, circumstances, situations, dates, and
allegations concerning the complaint. Additional pages may be added if necessary. Do not
include client identifying information in your description.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PCB Ethics Complaint Form | Revised October 2020 3
PART 3
Submit all relevant documents, as attachments, that will support the allegation(s) in your
complaint. Complaints submitted as hearsay and without appropriate evidence may be
dismissed as unfounded.
Have you attached additional documentation to this form?
□ Yes □ No
If yes, does any of the documentation contain confidential information protected by HIPAA or
other confidentiality law?
□ Yes □ No
If yes, have you attached a copy of a client consent release form or redacted confidential
identifying information?
□ Consent Form □ Redacted Confidential Identifying Information
PART 4
All complaints must be filed within four years from date the offense occurs. A certified
professional is required to file a complaint within 90 days. To determine if you have registered a
complaint in a timely manner, the following information is requested:
On what date(s) did the action or complaint occur?
______________________________________________________________________________
When were you first aware of the matter about which you are complaining?
______________________________________________________________________________
PART 5
If you know of others who have first-hand knowledge of the alleged conduct, please provide
the following information about them. Clients should not be listed unless including signed
consents.
Name:
Relationship to Complainant
Cell Phone:
Email:
PCB Ethics Complaint Form | Revised October 2020 4
Has the person against whom the complaint is being filed given you any explanation for such
alleged conduct? If yes, please state all such explanations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How do you view the explanation(s) given to you?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PART 6
Have you filed this complaint with any governing agency or organization? If yes, please list
the name of the agency and date filed?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PCB Ethics Complaint Form | Revised October 2020 5
Have you pursued resolution of your complaint through any internal grievance procedures of
an institution or agency? If yes, what is the status of your complaint?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PART 7
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 evidence, and
will be given the opportunity to submit rebuttal information and/or materials concerning the
complaint.
In filing an ethics complaint, the Executive Director may, at their discretion, proceed with an
investigation even if the complainant subsequently requests that the complaint be withdrawn.
I have completed the PCB Complaint Form to the best of my knowledge and am willing to
participate in a full investigation of all allegations noted in the complaint.
I, (print name) __________________________________________________________________
attest that the information contained herein is true and correct.
________________________________________________________________________
Signature
___________________________________
Date
Please make a copy of this entire document and any attachments for your records. Complaints
may be mailed, faxed, or emailed to PCB as follows (choose only one method below):
Mail
Pennsylvania Certification Board
298 S. Progress Avenue
Harrisburg, PA 17109
Email
info@pacertboard.org
Fax
717.540.4458
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ETHICS COMPLAINT FORM READ DIRECTIONS CAREFULLY (Pennsylvania Certification Board)

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Completed 3 June 2021

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