Complaint Form Question Title * 1. Name: Question Title * 2. Date: Date / Time Date Question Title * 3. Email address: Question Title * 4. Are you a Board Certified Pharmacist? Yes No None of the above Question Title * 5. Are you in a recertification extension year? Yes No None of the above Question Title * 6. Please indicate Pharmacy Specialty Ambulatory Care Cardiology Compounded Sterile Preparations Critical Care Emergency Medicine Geriatric Infectious Diseases Nuclear Nutrition Support Oncology Pediatric Pharmacotherapy Psychiatric Solid Organ Transplantation Not applicable Question Title * 7. BPS Credential Number Question Title * 8. Eligibility ID or Exam ID (examinees, if applicable) Question Title * 9. Please select a complaint category Scheduling or Displacement Issue CE Provider Issue Exam Content Relevance/Clarity Exam Time Allotment Testing Center Issue Application Process Certificates (not received, damaged, name issue) Misuse of the BPS Marks/Logos Report Unauthorized Use of BPS credential Certification Policy Issue Recertification Policy Issue Website Issue (access, ease of use, content) General issue Please provide a detailed description of the complaint category selected Question Title * 10. Attach supporting documentation as applicable PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Attach supporting documentation as applicable Question Title * 11. Attach supporting documentation as applicable PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Attach supporting documentation as applicable Question Title * 12. Follow-up Action from BPS Written Response Corrective Action Not Applicable Question Title * 13. Attach BPS supporting documentation for closeout PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Attach BPS supporting documentation for closeout Question Title * 14. Attach BPS supporting documentation for closeout PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Attach BPS supporting documentation for closeout Question Title * 15. BPS Closeout Date Date / Time Date Done
