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.

* 1. Person Filing Complaint:

* 2. Complaint Filed Against:

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

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

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