NOTICE OF ALLEGED VIOLATION FORM - Behavior Analyst Certification Board

Have you attempted to resolve the matter directly with the Subject?*

Yes
No

Does the Subject live, or did the incident occur, in one of the indicated states below?*

Yes
No

If the Subject of the alleged violation lives in one of the following states, then you must also report to the relevant state licensure agency or board.

For more information, please review the state licensure information.

Have you reported?*

Yes
No

You must first report to any relevant licensure or regulatory entity before submitting a Notice of Alleged Violation to the BACB. Once you have reported the necessary information to the relevant entity, you may return to complete this form.

Provide Case Information (e.g. case #, name of licensure or regulatory entity, name of investigator, date of notification)*

Notifier Information

Notifier Name*

First Last

Notifier Email Address*

Notifier Phone Number*

Notifier's relationship to the Subject of this Notice*

Subject of the Notice Information

Name of alleged Code violator ("Subject"). Please note, the BACB only has jurisdiction over certificants and applicants for certification. The BACB does not have jurisdiction over agencies.

Name of Subject*

First Last

Subject's Credential*

Board Certified Assistant Behavior Analyst
Board Certified Behavior Analyst
Board Certified Behavior Analyst-Doctoral
Applicant for certification

Did you contact the Subject's supervisor?*

Yes
No

Please enter the name of the supervisor contacted (if you don't know, type "unsure")*

City/State/Country of the Alleged Violation*

City State / Province / Region Country

Is this Notice related to another Notice of Alleged Violation?*

Yes
No

If yes, who was named in the other Notice?*

Name of Subject's Employer/Organization*

Description and Evidence of Alleged Violation

To submit a Notice, you MUST file it within six (6) months from the time you became aware, or should have been aware, of the alleged Violation(s) of the Code. You MUST include evidence to support each allegation. Notices submitted without supporting documentation will not be processed. Appropriate documentation MUST be linked to each alleged Code violation. Whether documentation is sufficient to process a Notice is in the discretion of the BACB. If documentation includes information about a service recipient, all identifying personal information must be removed (e.g., names, birth dates) from all documentation. Some examples of appropriate documentation include: emails, reports, time-stamped screen captures, links to webpages with the publicly available information. Alleged violations where the evidence is indirect (e.g., verbal interaction that was not recorded), you MUST submit an affidavit of witnesses to the interaction or observation.

How many alleged violations are you reporting?*

The notifier may allege no more than five individual Code violations.

Date(s) of Alleged Violation(s):*

I allege that the Subject of the Notice has violated the selected section of the Professional and Ethical Compliance Code for Behavior Analysts.*

Please review the BACB Professional and Ethical Compliance Code for Behavior Analysts.