BPS Complaint Survey Form

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1. Full Name: (Required.)

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2. Date:

Date/Time

Date

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3. Email Address: (Required.)

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4. Are you a Board Certified Pharmacist? (Required.)

Yes

None of the above

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5. Are you in a recertification extension year?

Yes

None of the above

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6. Please indicate Pharmacy Specialty (Required.)

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7. BPS Credential Number

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8. Eligibility ID or Exam ID (examinees, if applicable)

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9. Please select a complaint category (Required.)

Scheduling or Displacement Issue

CE/CPD Provider Issue

Exam Content Relevance/Clarity

Exam Time Allotment

Testing Center Issue

Application Process

Certificates (not received, damaged, name issue)

Misuse of the BPS Marks/Logos

Report Unauthorized Use of BPS credential

Certification Policy Issue (Including any issues related to certification)

Recertification Policy Issue (including any issues related to recertification)

Website Issue (access, ease of use, content)

General issue

MyBPS Portal Issues (password resets, name changes, etc.)

Exam Publication Errors

MyBPS Issues

Annual Maintenance Fees

Other (Please provide a detailed description of the complaint category selected)

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10. Please specify the resolution or action you would like BPS to consider in response to this complaint

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11. Attach supporting documentation as applicable

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12. Attach supporting documentation as applicable

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13. Follow-up Action from BPS

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14. Attach BPS supporting documentation for closeout

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15. Attach BPS supporting documentation for closeout

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16. BPS Closeout Date

Date / Time

Date

BPS Complaint Survey Form

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* 1. Full Name: (Required.)

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* 2. Date:

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* 3. Email Address: (Required.)

Question Title

* 4. Are you a Board Certified Pharmacist? (Required.)

Question Title

* 5. Are you in a recertification extension year?

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* 6. Please indicate Pharmacy Specialty (Required.)

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* 7. BPS Credential Number

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* 8. Eligibility ID or Exam ID (examinees, if applicable)

Question Title

* 9. Please select a complaint category (Required.)

Question Title

* 10. Please specify the resolution or action you would like BPS to consider in response to this complaint

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* 11. Attach supporting documentation as applicable

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* 12. Attach supporting documentation as applicable

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* 13. Follow-up Action from BPS

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* 14. Attach BPS supporting documentation for closeout

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* 15. Attach BPS supporting documentation for closeout

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* 16. BPS Closeout Date

1. Full Name: (Required.)

2. Date:

3. Email Address: (Required.)

4. Are you a Board Certified Pharmacist? (Required.)

5. Are you in a recertification extension year?

6. Please indicate Pharmacy Specialty (Required.)

7. BPS Credential Number

8. Eligibility ID or Exam ID (examinees, if applicable)

9. Please select a complaint category (Required.)

10. Please specify the resolution or action you would like BPS to consider in response to this complaint

11. Attach supporting documentation as applicable

12. Attach supporting documentation as applicable

13. Follow-up Action from BPS

14. Attach BPS supporting documentation for closeout

15. Attach BPS supporting documentation for closeout

16. BPS Closeout Date