Follow the steps to fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin with the section marked 'FOR OFFICE USE ONLY.' This section is intended for the board's administrative purposes and does not need to be filled out by you.
3. In the next section titled 'What is the practice area of the person?' mark the relevant box to indicate the practice area of the practitioner you are complaining about, such as Registered Nurse or Licensed Practical Nurse.
4. Provide detailed information about the practitioner, including their full name, date of birth, certificate or license number, home address, phone number, email, and place of employment.
5. Identify yourself in the 'Who are you?' section. Fill in your name, full address, and phone number. Include your email if you wish. If you are an employer, specify the agency or facility name and your title.
6. Specify your relationship to the licensee or certificate holder. Choose the appropriate option from the list provided.
7. Detail the date and location of the incident you are reporting. Provide as much information as possible for clarity.
8. List any witnesses to the incident, providing their names, addresses, and phone numbers. If there are no witnesses, write 'No witnesses' on the first line.
9. Indicate whether or not this complaint has been made to any other person or organization. Provide details if applicable.
10. Clearly print the details of your complaint in the designated section. Use additional pages if necessary, numbering and signing each additional page.
11. List the evidence you are including with your complaint. You can check off each type of document you are submitting to support your claim.
12. Finally, declare that the information provided is true and correct by filling in the date, printing your name, and signing the form with non-erasable ink.
13. After completing the form, save your changes. You can download, print, or share the form as needed.

Ensure your complaint is addressed by completing the MD MBoN Complaint Form online today.