Complaint Form

Submitter Information:
Address
City:
State:
Zip:
Licensee Information:
First Name:
Last Name:
Facility Information:
Address
City:
State:
Zip:
Complaint:
Please describe in detail:
  1. The sequence of events surrounding your complaint,
  2. The dates of occurrences, and
  3. The names of witnesses or participants.
Supplemental supporting documents can be emailed to rtboard@wv.gov.
Certification:

By checking this box, I certify that:

I certify, under penalty of perjury, to the truth and accuracy of all statements and answers. All representations made in this Complaint Form are true and correct.

By checking this box, I further certify that I am signing this Complaint Form. I attest that the information provided herein is complete and true to the best of my knowledge and belief. I understand that any documentation attached to the complaint becomes the property of the Board and will not be returned to me. Further, I agree to voluntarily appear and give testimony regarding the information in this complaint if called upon by the West Virginia Medical Imaging & Radiation Therapy Technology Board of Examiners.