Complaint Form

BYLAWS of the NATIONAL REGISTRY OF REHABILITATION TECHNOLOGY SUPPLIERS, INC. Revised and approved June 5, 2009 Page 18 of 24

Section 3. Ethics Committee. This committee is responsible for assuring that NRRTS Registrants adhere to the rules and procedures regarding the enforcement of the NRRTS Code of Ethics and Standards of Practice, as determined and mandated by action of the Board of Directors. The Ethics Committee will review both grievances brought by, or on behalf of, NRRTS Registrants and grievances brought by, or on behalf of, consumers or other stakeholders of the rehabilitation industry or profession, concerning a NRRTS Registrant.

Complaint Form

Today's Date*
MM slash DD slash YYYY
Enter name of individual who is filing the complaint:*
Name of Company (if applicable)
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
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Business Phone
Mobile Phone*
Are you a*
- Consumer
- Clinician
- NRRTS Registrant
- Other
If "Other" please describe:
Do you wish to be made aware of the findings of the Ethics Committee's findings and action?
- Yes
- No
Complaint Against
Name*
First Last
Date or date range of incident(s)
MM slash DD slash YYYY

A specific date or date range must be provided.
Name of employer*
The name of the person's employer who you are filing the complaint against.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Company Phone*
Nature of complaint (describe specific situation and provide specific dates if possible)*
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Consent*
By submitting this form, I agree that the statements I have made are true and accurate.
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Complaint Form

Complaint Against