Fillable Formal Complaint Form printable pdf download

NORTH CAROLINA BOARD of MASSAGE

AND BODYWORK THERAPY

Mailing Address: PO Box 2539, Raleigh, NC 27602 Phone: 919.546.0050

Location Address: 150 Fayetteville Street, Suite 1910, Raleigh, NC 27601

ORMAL

OMPLAINT

ORM

" The mission of NCBMBT is to regulate the practice of massage and bodywork therapy in the State of

"The mission of NCBMBT is to regulate the practice of massage and bodywork therapy in the State of North Carolina to ensure

North Carolina to ensure competency, and to protect the public health, safety and welfare."

competency, and to protect the public health, safety and welfare."

This is a Statement of Formal Complaint of Alleged Violation of the Massage & Bodywork Therapy Practice Act, Rules & Regulations

or Standards of Professional Conduct. If an investigation is deemed necessary, a copy of this form will be provided to the

individual against whom the complaint is filed.

INSTRUCTIONS:

Complete this form and summarize on a separate sheet of paper (print or type) the facts and circumstances, including dates and

events, warranting the complaint. Attach documentation that you think would help the NCBMBT in its assessment of this complaint.

Please sign and date all documents you have written and are submitting. Do Not enclose confidential documents such as patient or

employment records. (Statements from witnesses are not necessary at this time). Mail completed form with accompanying

documentation to the Board address listed above.

TODAY’S DATE: ___________________________

DATE OF ALLEGED INCIDENT: _______________________________

COMPLAINANT (PERSON FILING THE COMPLAINT):

Please note this section must be completed so the Board my notify you of receipt of the

complaint and to contact you should we need further information. If this section is left blank, the complaint cannot be processed.

Your Name: _________________________________________________________ NC License #

(if applicable):

__________________

Mailing Address: _______________________________________ City: ____________________ State: __________ Zip: __________

Phone Number: ___________________________ Email Address: ______________________________________________________

Signature of Complaint: ___________________________________________ Date Signed: ________________________________

RESPONDENT (INDIVIDUAL AGAINST WHOM THE COMPLAINT IS DIRECTED):

Name of Person: ______________________________________________________ NC License #

____________

(if applicable/known):

Name of Business: ___________________________________________ Business Phone #: __________________________________

Mailing Address: _________________________________________ City: _________________ State: _________ Zip: ____________

Physical Address of Business: _______________________________ City: _________________ State: _________ Zip: ____________

Phone Number: ____________________________ Email Address: _____________________________________________________

Indicate the section(s) of the Practice Act, Rules and Regulations or Ethical Principle(s) you believe have been violated:

____________________________________________________________________________________________________________

If you have filed a complaint about this matter with another agency, indicate to whom it was submitted and the approximate date(s)

submitted. Please include a copy of the Police Report (if applicable). Please list all that apply:

____________________________________________________________________________________________________________

What steps, if any, have been taken to resolve this complaint? _________________________________________________________

____________________________________________________________________________________________________________

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Formal Complaint Form

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