COMPLAINANT INFORMATION (Person filing complaint):

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COMPLAINT REGISTERED AGAINST:

NAME OF DIETITIAN OR PERSON PRACTICING DIETETICS IN VIOLATION OF WV STATE CODE:
PLACE OF BUSINESS OR LOCATION OF VIOLATION:
TELEPHONE NUMBER (IF AVAILABLE):
State your complaint and include details of events, dates, witnesses (with telephone numbers and addresses) and any pertinent documentation. Press Send at the bottom once you have completed this form.

If you need assistance in completing this form, call the Board office at:
1-800-293-9832.

IMPORTANT:

In Order to insure procedural due process, it may be necessary that your name will be disclosed to the practitioner or facility/institution in question
YOUR COMPLAINT IS A MATTER OF PUBLIC RECORD

WAIVER/RELEASE:

I, hereby authorize any investigator or other authorized representative of the West Virginia Board of Licensed Dietitians to disclose my name, if necessary, in investigating the complaint I have registered. I certify that the above information is true to the best of my knowledge. I consent that I will appear and testify to the facts in this complaint if called upon by the West Virginia Board of Licensed Dietitians.