Code of Ethical Conduct Complaint Form

This form is to be filled out by any person registering a complaint with the New York Peer Specialist Certification Board concerning an actively certified professional with the NYPSCB or a person applying for certification.

Please note this form cannot be saved and returned to at a later time. Have all required information prepared before beginning the form. The required information can be found in the NYPSCB Code of Ethical Conduct Handbook, beginning on page 10.

Once completed, the form contents will be sent confidentially to the NYPSCB Executive Director. Please email them directly with any questions.

Code of Ethical Conduct Complaint Form

This form is to be filled out by an person registering a complaint with the New York Peer Specialist Certification Board concerning an actively certified professional with the NYPSCB or a person applying for certification.

Part I

Name of person registering complaint:(Required)

First Last

Address of person registering complaint:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone number for person registering complaint:(Required)

Provide the name of the certified professional or applicant against whom the complaint is being registered:(Required)

First Last

Work Address of Individual:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Work Phone Number of Individual:(Required)

Nature of Complaint (check each one that is appropriate):(Required)

Improper Peer Specialist practices

Discriminatory practices

Violation of the New York Peer Specialist Certification Board's Code of Ethical Conduct

Violation of applicable Federal or State Law

Other

If other, please explain:(Required)

Part II

Please describe in as specific detail as possible the facts, circumstances, situation, and allegations concerning the complaint.(Required)

Please upload any written materials, data, or other documents which you think are relevant to your complaint.

Drop files here or Select files

Max. file size: 2 MB.

Part III

In order to determine if you have registered a complaint in a timely manner, the following information is requested:

On what date(s) did the action complained of occur?(Required)

When were you first aware of the matter about which you are complaining?(Required)

What is the most recent date of which you know of the alleged conduct prompting the complaint?(Required)

Part IV

Do you know of others who have knowledge of the alleged conduct?(Required)

Yes

No

Please provide the name of another person who has knowledge of the alleged conduct:(Required)

First Last

Please provide contact information for the individual:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone number for the individual:(Required)

Is there another individual that has knowledge of the alleged conduct?(Required)

Yes

No

Please provide the name of another person who has knowledge of the alleged conduct:(Required)

First Last

Please provide contact information for the individual:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone number for the individual:(Required)

Did you speak to the person against whom the complaint is being filed?(Required)

Yes

No

If yes, please explain the details and date of communication:(Required)

Has the person against whom the complaint is being filed given you an explanation for such alleged conduct?(Required)

Yes

No

If yes, please state all such explanations:(Required)

How do you view the explanations given to you?(Required)

Part V

Have you filed this complaint with any Federal, State, or Local Government agency?(Required)

Yes

No

If yes, name of agency complaint was filed with:(Required)

Address of agency complaint was filed with:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of filing:(Required)

MM slash DD slash YYYY

If not, do you intend to file with another agency?(Required)

Yes

No

Name of agency you intend to file complaint with:(Required)

Address of agency you intend to file complaint with:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have you pursued resolution of your complaint through internal grievance procedures of an institution or agency?(Required)

Yes

No

If yes, what is the status of the complaint and the name of the institution or agency?(Required)

Have you discussed the complaint with a supervisor?(Required)

Yes

No

Name of the supervisor:(Required)

First Last

Date the complaint was discussed with supervisor:(Required)

MM slash DD slash YYYY

Have you commenced civil or administrative action or proceeding in the Federal courts based on this complaint?(Required)

Yes

No

If yes, what is the status?(Required)

Part VI

In the event NYPSCB is unable to locate you to discuss the complaint, please provide the following information for a person who knows how to contact you:

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Attestation

I understand that the person against whom the complaint is being registered shall be fully informed concerning this formal complaint process and will be given a copy of this complaint form in order to allow the individual the opportunity to submit rebuttal information and/or materials concerning the complaint. I have completed this 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 swear that the information contained herein enclosed herewith is true and correct.

Signature(Required)

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY