Complaint Tracker System

Online Complaint Submittal Form - Special Licensing

The Division of Licensing Services, Bureau of Special Licensing provides this Online Complaint Form which allows anyone with knowledge or concerns about a suspected rule violation to submit a complaint through this web page. A complaint is a suspected violation of Arizona state rules and/or statutes governing the licensed practices of audiologists, speech-language pathologists, speech-language pathology assistants, hearing aid dispensers, and hearing aid dispensing businesses.

The Bureau of Special Licensing has the authority to investigate complaints related to suspected violations of the statutes (Arizona Revised statutes Title 36, Chapter 17) and rules (Arizona Administrative Code Title 9, Chapter 16, Articles 2 and 3) that govern the licensure of speech and hearing professionals.

Please review the following prior to submitting the complaint allegation.

Complaint Frequently Asked Questions (FAQs)

When filling out this form, information that is required is indicated by a red asterisk (*). Click "Start" to begin complaint.

Enter Provider Information

* Speech-Language & Hearing Provider Name

Provider License Number

* Address

Provider Phone Number

* City

* State

* Zip

Nearest Cross Streets

Licensee Type

Audiologist

Hearing Aid Dispenser

Hearing Aid Dispensing Business

Speech-Language Pathologist

Speech-Language Pathology Assistant

Enter Complaint Information

* Start Date and Time of Alleged incident/Violation

End Date and Time of Alleged incident/Violation

* Describe what happened, including when (time and date), and how, who was involved, and if this happened before.

Please attach any evidence such as supporting documentation or pictures relevant to the complaint.

* Is Evidence Available?

Yes No

* Has the licensee been contacted about this complaint?

Yes No

* Has any other agency (DCS, APS, AHCCCS, police, etc) been contacted?

Yes No

Please add any individuals such as resident, patient, witness, staff member, etc. or specific locations where the complaint occurred.

Enter Complainant's Information

Please note Full name and contact information is still required to submit complaint. Although anonymous reports are accepted, we request your contact information so that we may contact you if we need additional information to properly address your complaint.

* Do you feel that the release of your name may result in substantial harm?

Yes No

* First Name

* Last Name

Contact Information

Please enter a contact email - You will receive an email at this address to verify your complaint submission

* Email Address

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* Primary Phone Number

Alternate Phone Number

May leave a message at the phone number provided

Address (Number & Street)

Address 2 (Number & Street)

City

State

Zip

Client First Name

Client Last Name

Client Age

* Complainant Source

Please provide me the final determination

* By submitting this form electronically, I state that I have read the complaint contents and the statements are true by my personal knowledge or I believe them to be true.