Please submit this form if you would like to file a complaint against a nursing program. Complainant Information (Your Information) Do you wish to remain anonymous? * Yes No Complainant Name (Enter N/A if Anonymous) * Complainant Address: Complainant Phone Number Complainant Alternate Phone Number Complainant Email Address: School/Program Information School Name: * Program Type: * ADN BSN LPN APRN CNA/LNA CMA Other… Enter other… Program Address (city and state are required): * Program Phone number Dates Attended Complaint Facts: Please explain your complaint and provide evidence of your complaint (attachments can be added) *Be sure to include complaint facts including: dates, times and locations of incidences; statements made; and any behaviors which were observed.Do you have evidence of your complaint / attachments that need to be uploaded? * Yes No May a copy of this complaint be shared with the school against which you are complaining? * Yes No Please explain the resolution or outcome you are seeking in filing this complaint: *Witness Information Please include witness names, best contact information, and statements regarding incidents here: If you have documents to support your complaint, Witness statements or any other documentation you believe will be useful, please email them directly to [email protected]. Electronic Authorization Please enter your Electronic Signature * Reset Sign above Today's Date * What code is in the image? * Enter the characters shown in the image.Submit
