Committee on Professional Ethics Code of Ethics Violation Complaint Form Please provide the following information: Name of the Athletic Trainer who has allegedly violated the NATA Code of Ethics and/or Membership Standards * Title * Email (if known) Employer (if known) Phone Number (if known) Address (if known) City (if known) State (if known) - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code (if known) Please identify the principle(s) and subprinciple(s) of the NATA Code of Ethics and/or section(s) of the NATA Membership Standards that you feel has been violated. * View the Code of Ethics. View the Membership Standards. Please provide a detailed factual scenario setting forth all relevant facts in support of your assertion of a violation or violations. * Please provide the name(s) and contact information (phone # preferred) of any and all witnesses to the alleged violation or violations. * Please provide a list of all documentation (and all copies of those documents) supporting your assertion of alleged violation or violations, including media reports if applicable. * Individual Filing Complaint – this is confidential and mandatory in order to file a complaint * Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year Contact information of individual filing complaint: Complaintant Name * Complaintant Email * Re-Enter Complaintant Email * Complaintant Phone Number * Complaintant Address * Acknowledgment By submitting this Ethics Complaint, I charge the Respondent identified herein with a violation(s) of the NATA Code of Ethics and/or Membership Standards and Sanctions. I understand that I am required to keep the information that has been and will be submitted concerning this ethics proceeding confidential, as set forth in the Procedures for Processing Complaints of Ethical Violations and subject to all applicable exceptions. I also understand that the Respondent may receive a complete, redacted copy of this document, as well as other information that is submitted with regard to the ethics proceeding. I acknowledge and agree that the NATA may contact individuals who may be witnesses. I allow the NATA to provide a copy of this Ethics Complaint to the NATA staff and others as reasonably necessary for the conduct of an investigation. Further, I understand that some or all of the information submitted with regard to the ethics proceeding may be disclosed (in either redacted or non-redacted form) to the NATA’s members and others following a final determination. I further certify that the factual allegations made in this Ethics Complaint are true and accurate to the best of my knowledge and that these ethics charges are made in good faith. I agree agree * Upload a file Upload More informationFiles must be less than 2 MB. Allowed file types: jpg jpeg png txt rtf pdf doc docx ppt pptx. Submit
