NATIONAL BLINDNESS PROFESSIONAL CERTIFICATION BOARD
CODE OF CONDUCT COMPLAINT FORM

The National Blindness Professional Certification Board (NBPCB) maintains a Code of Conduct which is intended to provide standards for ethical behavior of Structured Discovery professionals and training facilities certified by our organization. This Code of Conduct and our Guidelines and Procedures for Processing Complaints can be found on our website, www.nbpcb.org or by request at admin@nbpcb.org.

If you have been a victim of sexual assault, you can contact RAINN, the nation's largest anti-sexual violence organization for help at 800-656-4673.

A complaint alleging a violation of our Code of Conduct can be initiated by filling out this form and submitting it, along with any supporting documentation, to us at admin@nbpcb.org. If you would prefer to talk to someone on the phone, we can call you.

NBPCB accepts complaints from any person who has a verifiable reason to believe that a certified individual or training facility has violated our Code of Conduct within the past five years. NBPCB reserves the right to act as the Complainant when there is a reasonable suspicion to proceed with an investigation, or to extend the reporting period when the alleged violation is particularly egregious.      

Please note that only completed and signed forms can be accepted before an investigation of the alleged violation can begin. Any questions or requests for accommodations can be submitted to us at admin@nbpcb.org.

Type your response below each question. Provide as much information as you feel comfortable doing so at this time. Later we may need to ask you some additional questions to get a clearer picture of the incident(s) you are reporting.

Section I

Your name:*

Your preferred address:*

Your preferred phone number:*

Your preferred email address:*

Section II 

Name of individual alleged to have violated our Code of Conduct:*

Their address, if known:

Their phone number, if known:

Their employer, if known:

How do you know this person?*

Do you have any emails, text messages or any other physical documents that would be helpful for us to have?* 
Yes      No

Section III

Describe the incident or incidents that occurred with as much detail as you feel comfortable doing so at this time. It would be helpful to include dates, locations, and names of any witnesses. (If filling this form out on paper, please attach additional pages if necessary.)*

STATEMENT OF UNDERSTANDING and RELEASE

1. By providing my electronic signature at the end of this document, I affirm that the allegations set forth in this complaint and any accompanying materials are based on my own personal experience and are true and correct to the best of my knowledge and belief.  I also affirm that I have submitted any and all information and materials that I believe relate to the allegations set forth in the complaint currently available to me.
2. I acknowledge that I understand that all information, including a copy of this complaint form, any accompanying letters of complaint and supporting documentation will be used during the investigation process of this complaint and may be disclosed to NBPCB investigators and its attorneys, the individual alleged to have violated the NBPCB Code of Conduct, to potential witnesses, and when applicable, to authorities required by law, regulation or court order.
3. Although not required, I understand that I may have a representative of my choosing with me during investigative interviews and that I   am responsible for arranging for all aspects of the presence of my representative at any meeting(s) with investigator(s).  The role of the representative during these meetings will be to provide me with support and consultation and not to respond for me or disrupt the proceedings.
4. I acknowledge that I have read the Guidelines and Procedures for the Processing of Complaints and I understand the process and have sought clarification from NBPCB when necessary. I also understand that I can request accommodations during this process. 
5. Further, by signing this form, I hereby grant permission to the alleged perpetrator and any organizations that may be involved to release any relevant information or records relating to my complaint to NBPCB.