Name *

your information will be kept confidential in regards to the complaint being filed

First Name

Last Name

Phone

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Name of Individual *

Name of Individual who you are filing a complaint against

First Name

Last Name

Address of Incident

Please provide the address where the incident occurred

Address 1

Address 2

City

State/Province

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Complaint(s) *

Please select the issue(s) you are reporting:

An individual employed / volunteering as an Athletic Trainer without a BOC certification (non-certified Athletic Trainer)

Other licensed healthcare professional in California claiming to be an Athletic Trainer.

Athletic Training Students providing direct care to patients without supervision from a BOC-certified Athletic Trainer or other Licensed Healthcare Professional

Harm caused to a patient under the care of an Athletic Trainer