California Athletic Trainers' Association (CATA) Violation Report

This report form is to be used by a member of the public (i.e., consumer, patient, employer, colleague) who wishes to report one of the following issues: 1) harm caused to a patient while under the care of an Athletic Trainer; 2) a person employed/volunteering as an Athletic Trainer without BOC certification; 3) a licensed health-care professional in CA claiming to be an athletic trainer; or 4) athletic training student(s) providing patient care without direct supervision from a supervising BOC-certified Athletic Trainer or licensed health-care professional. Complainants identity will be held strictly confidential.

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* 1. Person Filing Complaint:

First Name: *

Last Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Home Phone (please include area code)

Business Phone (please include area code)

Email Address *

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* 2. Complaint Filed Against:

Name:

Company:

Address:

Address 2:

City/Town:

State:

Email Address:

Phone Number:

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* 3. Which violation are you reporting? (select all that apply)

Harm to Patient

Non BOC-certified person employed/volunteering as an Athletic Trainer

Licensed health-care professional claiming to be an Athletic Trainer

Unsupervised athletic training students

Other (please specify)

California Athletic Trainers' Association (CATA) Violation Report

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* 1. Person Filing Complaint:

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* 2. Complaint Filed Against:

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* 3. Which violation are you reporting? (select all that apply)

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* 4. Please provide a detailed factual scenario setting forth all relevant facts in support of your assertion of a violation or violations:

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* 5. Please provide a list of all documentation supporting your assertion of said violation or violations: