NOTICE OF ALLEGED VIOLATION FORM

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.

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.

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.

The BACB expects all Notifiers to exercise due diligence before reporting a matter to the BACB. This includes reviewing Section 7.0 of the Code, state laws, and any mandated reporting requirements. If the Subject of the Notice was reported to authorities, include information and a status update regarding that report.

I hereby declare that:

1. I am of legal age to sign this Notice.
2. I have direct knowledge of the alleged violation(s).
3. I agree to the terms and conditions stipulated in this Notice and I affirm that I have only provided truthful and accurate information in this Notice.
4. I waive any right or claim I may have against the BACB for the processing of this Notice and/or the release of information relating to this Notice, response to the subject, or determination of the BACB.
5. The information provided in this Notice is true and accurate to the best of my knowledge.
6. If applicable, I consent to and agree to assist with the investigation including, but not limited to, the submission of any and all information required by the BACB.
7. You are prohibited from engaging in vexatious or harassing communications with BACB Personnel. You must immediately comply with any cease and desist notice issued to you from the BACB
8. If I am not the recipient of services or a parent or legal guardian of the recipient of services, I have obtained permission to file this Notice from the recipient of services or parent or legal guardian of the recipient of services.
9. I understand that I may not appeal BACB determinations in which I am a Notifier. I understand that I will not be provided with a copy of the BACB’s case files, including but not limited to, the response of the Subject of the Notice, related documentation, or records of Review Committee or Appeal Committee deliberations. I agree not to subpoena the BACB or name the BACB as a defendant in any litigation or third-party action.
10. I understand that the BACB may release this Notice and related documentation, including, but not limited to, my information as the Notifier, to the Subject of the Notice. I understand that if I am submitting this Notice against a BCaBA or RBT, a copy of this notice will be provided to the relevant Supervisor and/or Responsible Certificant.
11. I understand that the BACB may release this matter, including, but not limited to, my identity, the identity of the Client and Certificant, response of the Subject, and the outcome of the matter, if such information is required or requested by any state or government official or agency. The BACB may, in its sole discretion, comply with any governmental agency request for release of this Notice, the Subject's response, and determinations, if any, by the BACB at any time during or following the BACB's processing of this Notice.
12. I agree to participate in the investigation of the Notice, including, but not limited to, providing consent for the behavior analysts named herein and their agency, school or organization, to release the comprehensive case file (including client or student service record) as may be needed to defend against the allegations provided herein.