ETHICS AND DISCIPLINARY REVIEW

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM^®)
2001 K Street NW, 3^rd Floor North
Washington DC, 20006
Phone: (888) 381-1140
Fax: (202) 381-1141
E-mail: [email protected]

State Report Form for Professional Ethics Violation

"*" indicates required fields

Reporting Agency Information

State Regulatory Agency*

State Official Name*

First Last

Work Phone:

Work Email*

Disciplinary Case Information

Who committed this violation?

Name*

First Last

Date of Birth*

State License #*

Initial Licensing Date*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of initial disciplinary notice*

Nature of the Case: (Check all that apply)*

False Advertising/Misleading Information

Boundary Violations/Unprofessional Conduct

Unlicensed Activity

Fraud

Cheating/Examination Irregularity

Malpractice/Negligence

Criminal Conviction

Fitness to Practice

Others(Violation not listed above – please add specific details in the description of your complaint)

Brief description of the case*

Current Case Status*

License Status*

Supporting Documentation

Please attach a clear and concise description of the case, include facts, dates, reports.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

The NCCAOM^® Professional Ethics and Disciplinary Committee (PEDC) has the authority to investigate complaints received and to impose sanctions on Licensed Acupuncturists. Please refer to the NCCAOM^® Procedures for Upholding Professional Conduct to understand the process and timeline for evaluating complaints received against Licensed Acupuncturists.

If you have questions about the reporting process, contact NCCAOM’s Professional Ethics Department either by phone (888) 381-1140 or by email at [email protected].

CONFIDENTIALITY NOTICE:

The information provided in your submission is confidential and intended solely for the NCCAOM's Professional Ethics and Disciplinary Committee (PEDC). By submitting this information, you acknowledge and agree that this information may be used to initiate an investigation into the underlying accusations. The investigatory process shall remain confidential between the Diplomate and the PEDC unless and until a final disposition of the matter requires publication. Please direct any questions to PEDC Liaison at [email protected].