Incident Request Form

Person Filing The Incident:

First name*

Last name*

Street address*

City*

State/Region*

Zip code*

Daytime Phone Number*

Email*

Examinee/Certificant Involved in Incident:

Name of Individual*

Name of Business*

Business Address*

City *

State*

Zip Code*

Phone Number*

Email Address*

Details of the Incident:

1) Please describe the incident in detail. Include all facts, dates, and names of individuals involved. Attach copies of receipts, bills, and other correspondence using the Supporting Documents field below.*

2) Have you contacted the business or individual about this incident?*

Yes

3) Have you filed a report regarding this matter with another agency?*

Yes

4) Has a regulatory board been notified of this incident?*

Yes

5) Has a regulatory board taken action on this individual related to this incident?*

Attestation:

These statements are true and accurate to the best of my knowledge. I understand that these statements may be used in all phases of NHA’s investigations and administrative procedures.

Incident Attestation Signature*

Incident Attestation Date*

Year/Month/Day

We will not disclose your identity to relevant parties unless you sign the following statement:

By signing below, I authorize NHA to disclose my identity as the person who filed this incident report. My identity may be disclosed to the subject(s) of this report and other persons during the course of the investigations.

Incident Disclosure Signature

Incident Disclosure Date

Year/Month/Day

Supporting Documents