Colorado Academy of Nutrition and Dietetics
1805 South Bellaire Street, Suite 505
Denver, CO 80222



Acts of Harm Complaint Form



COMPLAINT FILED BY:


Date
    
Name (Last,First,Middle Initial)

Company (if applicable)

Street Address

City

State

Zip

Cell/Home phone number

Business phone number

E-mail address


COMPLAINT FILED AGAINST:

    
Name (Last,First,Middle Initial)

Company (if applicable)

License Number (if known)

Specialty (if known)

Street Address

City

State

Zip

Cell/Home phone number

Business phone number

E-mail address

Date(s) of the Incident


NATURE OF COMPLAINT

Check all that apply
Substandard practice Monetary abuse Misdiagnosis of condition/problem
Mental/physical disability Abuse of client/patient Sexual contact with client/patient
Non-compliance with Board order Criminal conviction Credentials falsely claimed
Overutilization Addiction to drugs/alcohol Failure to release records
Fraud Client abandonment Documentation issues
Improper prescriptions Poor communication Inappropriate care of child/client/patient


DESCRIPTION OF COMPLAINT

In the space provided please give any additional information.


Provide a chronological summary of your complaint, including dates.

List names, addresses and telephone numbers of witnesses including other professionals. Report any police investigation including case number and submit the written report (if available).

Please list other documents relevant to your complaint such as letters and other correspondence, police reports, contracts, witness statements, which you could provide upon request.

Have you filed a complaint with anyone else, retained an attorney, or had the case reviewed by any experts? If so, please provide detailed information for each.

I ATTEST THAT ALL STATEMENTS MADE BY ME RELATED TO THIS COMPLAINT ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
    
Name (Last,First,Middle Initial)

Date
      
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