Complaint Form (Page 3 of 3) in pdf

FOR OFFICE USE ONLY

COMPLAINT CHECKLIST

NOTICE TO ACCUSED:

________

Date letter mailed to accused outlining charges and requesting a written response.

________

Date written response received from accused.

________

If no response received, date second letter mailed, via certified mail, to accused outlining

charges and requesting written response.

INVESTIGATION:

Licensed? __ Yes __ No

If yes, license number: ___________

Date received: ____________ Expiration date:__________

Any prior complaints against accused? __ Yes __ No

If yes, date and result of prior complaint:_________________________

Is there ongoing civil and/or criminal litigation regarding accused? __ Yes __ No

If yes, provide details:______________

________________________________________________________________________________________________________

Investigator’s comments regarding jobsite visit: ________________________________

Date jobsite visited: __________

________________________________________________________________________________________________________

If corrective action is required, is accused willing to perform corrective action? __ Yes __ No

If yes, time limit for corrective action to be performed: ___________________________________________________________

Has investigator verified whether corrective action has been completed? __ Yes __ No If yes, date verified: ________________

Inspection performed? __ Yes __ No If yes, Property Inspected by:_______________ Date Property Inspected: ___________

*Attach inspection report

HEARING:

Date of Hearing: _________________

Place of Hearing: ________________ Time of Hearing: _________________

Date Formal Complaint and Notice of Hearing mailed to accused: __________________________________________________

DECISION AND ORDER:

Recommendation/Resolution: _______________________________________________________________________________

Final Resolution Date: ______________

Date notification of final resolution mailed to accused: ___________________

APPEAL:

Board decision appealed? __ Yes __ No

If yes, date notice of appeal received: _________________________________

Court where appeal filed: ________________________

Attorney representing appellant: _____________________________

Date Bill of Exceptions and Record transmitted to Chancery Court: _________________________________________________

Post Office Box 320279 · Jackson, MS 39232-0279 · 2679 Crane Ridge Dr., Suite C · Jackson, MS 39216 · 601-354-6161 · Fax 601-354-6715

Complaint Form Page 3