COMPLETION OF THIS FORM IS VOLUNTARY

PLEASE PRINT CLEARLY OR TYPE

Your Name (First, Middle, Last)		Complaint Against
Address		Profession
City State Zip		Address
County	Area Code Home Phone # ( )	City State Zip
Date of Birth	Area Code Work Phone # ( )	County	Area Code Phone # ( )
Email Address

PLEASE NOTE: SEE PAGE 3 FOR IMPORTANT INFORMATION AND A LIST OF THE PROFESSIONS, OCCUPATIONS, ACTIVITIES AND BUSINESSES REGULATED BY THE DEPARTMENT OR BOARDS ATTACHED TO IT.

1. When did the incident occur? If you do not know the exact date, make as close an estimate as possible.

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2. Did the incident occur in a facility, private office, home, etc.? Provide specific names and addresses of each place involved in the incident.

_____________________________________________________________________________________________

3. If you have spoken to the person about your complaint, what was his/her response?

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4. If your complaint is, or has been, under consideration by any agency or court anywhere, provide information.

_____________________________________________________________________________________________

5. Who else has information related to this incident? Provide names, addresses, and phone numbers for those persons.

_____________________________________________________________________________________________

[PLEASE BE SURE TO SIGN YOUR NAME ON THIS FORM AND DATE IT]

#102 (Rev. 10/09)

Sec. 440.03, Stats. Page 1 of 3

Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Regulation & Licensing

6. Describe the incident you are complaining about. Include as much specific information as possible. Attach additional pages if needed.

ATTACH COPIES OF ANY DOCUMENTS RELEVANT TO THE INCIDENT. (NOTE: IT IS VERY IMPORTANT TO KEEP ALL MATERIAL RELATED TO THIS COMPLAINT SUCH AS BILLINGS, PERSONAL NOTES, PILL BOTTLES OR OTHER MATERIALS).

_____________________________________________________________________________________________

___________________________________________________________________ __________________

SIGNATURE (First, Middle, Last) DATE FORM SIGNED

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Wisconsin Department of Regulation & Licensing

GENERAL INFORMATION

Staff in the Division of Enforcement of the Wisconsin Department of Regulation and Licensing investigate, and when appropriate, prosecute complaints against persons, organizations and business establishments regulated by the department and the regulatory boards attached to it. (A list of the groups regulated appears below). The boards and department establish and enforce standards of professional conduct for licensed persons and businesses and ensure that other persons are not practicing those occupations or professions and operating businesses unless licensed. The department and boards generally have the authority to reprimand a licensee, suspend or revoke the license of a licensee, limit the licensee's license or dismiss the complaint. Some boards can make additional determinations. The department and boards do not have the authority to award monetary damages or compel corrective actions, as these are primarily court functions.

This form is provided as a convenient means to submit the facts necessary to initiate an investigation. Your complaint will be reviewed to determine whether there appears to be a violation of the law or rules enforced by the appropriate board or the department. If the matter is investigated, it is likely that all persons with information about the case, including the person about whom you are complaining, will be contacted. Once the investigation is complete, a decision will be made as to an appropriate course of action to take. The case may be closed or formal disciplinary action may be commenced against the person about whom you are complaining. If the latter action is taken, there will likely be a hearing before either the relevant board or an administrative law judge. In any event, both the person making the complaint and the person against whom the complaint is made will be advised of the action taken in the case. Under Wisconsin's Open Records Law (Wis. Stats., Ch. 19), complaints will generally be available for review on request from a member of the public after board or agency action is completed.

Sec. 440.042(2), Stats., provides: "Any person who in good faith testifies before the department or any examining board, affiliated credentialing board or board in the department or otherwise provides the department or any examining board, affiliated credentialing board or board in the department with advice or information on a matter relating to the regulation of a person holding a credential is immune from civil liability for his or her acts or omissions in testifying or otherwise providing such advice or information. The good faith of any person specified in this subsection shall be presumed in any civil action and an allegation that such a person has not acted in good faith must be proven by clear and convincing evidence."

If you have any questions about this form or the procedure that will take place, please contact the department staff at (608) 266‑7482.

The following professions, occupations, activities and businesses are regulated by the boards and department:

Accountants-Certified Public Accountants and Firms		Landscape Architects
Acupuncturists		Manicurists and Manicuring Establishments
Aestheticians and Aesthetician Establishments		Marriage and Family Therapists
Appraisers-Licensed-General and Residential Real Estate		Massage Therapists and Body Workers
Architects		Midwives, Licensed
Architectural and Engineering Corporations		Music, Art and Dance Therapists
Athlete Agents		Nurses-Advanced Practice-Licensed Practical-Midwife-Registered
Athletic Trainers		Nursing Home Administrators
Auctioneers and Auction Companies		Occupational Therapists and Occupational Therapy Assistants
Audiologists		Optometrists
Barbering and Cosmetology Establishments		Perfusionists
Barbering and Cosmetology Managers		Pharmacies
Barbering and Cosmetology Practitioners		Pharmacists
Boxing Clubs and Exhibitions		Physical Therapists and Physical Therapist Assistants
Cemetery Preneed Sellers		Physicians (doctors of medicine and osteopathy)
Cemetery Salespersons and Authorities		Physician’s Assistants
Charitable Organizations		Podiatrists
Chiropractors		Private Detectives and Agencies
Crematory Authorities		Private Practice School Psychologists
Dental Hygienists		Private Security Persons
Dentists		Professional Counselors
Designers of Engineering Systems		Professional Employers-Group-Organization
Dietitians		Psychologists
Drug Distributors and Manufacturers		Real Estate Brokers, Corporations and Partnerships
Electrologists and Electrology Establishments		Real Estate Salespersons
Engineers-Professional		Respiratory Care Practitioners
Firearms Certifier		Sanitarians-Registered
Fund Raising Counsel		Schools and Instructors of Barbering, Cosmetology,
Fund Raisers-Professional		Aesthetics, Electrology and Manicuring
Funeral Directors		Social Workers
Funeral Establishments		Soil Scientists-Professional and Soil Science Firms
Geologists-Professional and Geology Firms		Speech Language Pathologists
Hearing Instrument Specialists		Substance Abuse Counselors (Prevention Specialists, Independent
Home Inspectors		& Intermediate Clinical Supervisors)
Hydrologists-Professional and Hydrology Firms		Time‑Share Salespserson
Interior Designers		Veterinarians
Land Surveyors		Veterinary Technicians

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