Complaint Form for Violation of Code of Ethics - Health Professional

Complaint Form for Violation of Code of Ethics - Health Professional

Submitting an Ethics Complaint-RDs, DTRs, and Other Healthcare Professionals
Registered dietitians, dietetics technicians, registered or other healthcare professionals who are aware of an alleged violation of the Code of Ethics for the Profession of Dietetics should use the following complaint form.

Please complete all the items on the complaint form (please print), including as much supporting evidence as possible. Please review the ADA/CDR Code of Ethics for the Profession of Dietetics before completing the complaint form. Forward the completed complaint form to Harold Holler, RD, Director of Governance, American Dietetic Association, 120 South Riverside Plaza, Suite 2000, Chicago, Illinois 60606-6995 in an envelope marked CONFIDENTIAL.

Please note the deadline for filing a complaint specified in Section "Ethics Cases" (page 5, Code of Ethics) of the procedures for submitting a complaint. If the ethics process goes forward, a copy of the complaint will be sent to the respondent.

Confidentiality procedures will be followed as set forth on page 13, Code of Ethics. Please keep this matter confidential. Please feel free to contact Harold Holler (800/877-1600, extension 4896) if you have any questions. (PDF Version)

 

COMPLAINT OF ALLEGED VIOLATION OF THE ADA/CDR CODE OF ETHICS FOR THE PROFESSION OF DIETETICS

This form must be completed to file a complaint under the ADA/CDR Code of Ethics. If it is determined that the ethics process should proceed, a copy of the complaint will be forwarded to the respondent.

PART I—PLEASE COMPLETE ALL ITEMS.

NAME OF COMPLAINANT (Person making complaint):

______________________________________________________________________

ADDRESS OF COMPLAINANT:

______________________________________________________________________

DAYTIME TELEPHONE NUMBER OF COMPLAINANT:

______________________________________________________________________

ARE YOU A MEMBER OF THE AMERICAN DIETETIC ASSOCIATION? YES NO

ARE YOU A REGISTERED DIETITIAN? YES NO

ARE YOU A DIETETIC TECHNICIAN, REGISTERED? YES NO

LIST ANY OTHER CREDENTIALS:

______________________________________________________________________

PLACE OF EMPLOYMENT:

______________________________________________________________________

POSITION:

______________________________________________________________________

ADDRESS:

______________________________________________________________________

PART II—PLEASE COMPLETE ALL ITEMS.

NAME OF RESPONDENT:

______________________________________________________________________

ADDRESS OF RESPONDENT:

______________________________________________________________________

PLACE OF EMPLOYMENT:

______________________________________________________________________

ADDRESS:

______________________________________________________________________

DAYTIME TELEPHONE NUMBER:

______________________________________________________________________


PART III—PLEASE COMPLETE ALL ITEMS.

1. DESCRIBE ALLEGED VIOLATION INCLUDING PLACE, DATE AND SURROUNDING CIRCUMSTANCES OF ALLEGED VIOLATION. (Attach a list the statement(s)/action(s) of respondent; list the objection(s) to the statement(s)/action(s) with substantiation; list the section(s) of the Code of Ethics allegedly violated).

2. ATTACH SUPPORTING DOCUMENTATION OF ALLEGED VIOLATION.

3. LIST NAMES, ADDRESSES AND THE DAYTIME TELEPHONE NUMBER OF PERSONS WHO MIGHT HAVE KNOWLEDGE OF ALLEGED VIOLATION.

4. HAS THIS COMPLAINT BEEN REFERRED TO:

a. A court of law: YES NO If “yes,” is a decision pending? YES NO

Please provide details:

b. A state board of examiners (licensing board) of medical professionals or dietitians or other administrative body ? YES NO

If “yes,” is a decision pending? YES NO

Please provide details:


I agree to cooperate fully with The American Dietetic Association in disposing of this complaint. I swear/affirm that the information submitted in and with this form is true and correct to the best of my knowledge and belief. I further agree that I will keep this matter confidential.

___________________________________________

Signature of Complainant

Subscribed and sworn to before me this ______ day of _________________, 20___.

 

___________________________________________

Notary Public

 

Please return this form in a confidential envelope to:

Harold Holler, RD
Ethics Committee
American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
312/899-0040 ext. 4896

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