Follow the steps to complete the worksheet effectively.

1. Click ‘Get Form’ button to obtain the worksheet and open it in your online editor.
2. Begin by filling in your name, email, and address in the designated fields. It is important to provide accurate contact information as it may be required for follow-up communications.
3. Enter the name of your employer along with the employer's address. Including your work phone and cell phone numbers will help facilitate communication.
4. Specify your credential or license along with its expiration date, as this provides context for your qualifications and affiliation.
5. In the next section, write the name of the person who is alleged to have violated ethics, complete with their email, home address, and employer details.
6. Identify the specific ethical principles and subsections that are allegedly violated. Reference the Code of Ethics available on the Iowa Board of Certification website to ensure accuracy.
7. Provide a detailed description of the alleged violation. Include key details such as involved individuals, circumstances, dates, and locations, while avoiding patient names for confidentiality.
8. List any individuals who have firsthand knowledge of the situation, providing their contact information for further inquiries.
9. Indicate whether there are any clients or patients involved who may be subject to federal confidentiality laws. If yes, be prepared to include their willingness to sign a release form.
10. State whether you have pursued any resolution of your complaint through relevant agencies and provide the status of that complaint.
11. Attach any relevant documentation that supports your allegation and aids the investigation process.
12. Finally, review the acknowledgment section, affirming that all information is true and that you are willing to participate in the investigation. Sign and date the form before submission.

Complete and submit your IA Ethics Violation Allegation Worksheet online today to ensure your concerns are heard.