Wufoo

Licensed Lay Midwifery Complaint Form

Women’s Health Section receives and investigates complaints against licensed and non-licensed lay midwives in Arkansas for non-compliance with the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas. The Arkansas State Board of Nursing (ARSBN) investigates complaints about licensed nurses, including certified nurse midwives. If you wish to file a complaint regarding a certified nurse midwife, please refer to the website https://www.arsbn.org for more information.

Name of Midwife Being Reported * First Last
Address of Midwife Being Reported
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Person Filing Complaint * First Last
Email *
Address of Person Filing Complaint
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relationship to Midwife *
Witness Information
Witness #1 First Last
Phone Number ### - ### - ####
Email
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Witness #2 First Last
Phone Number ### - ### - ####
Email
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please answer each question below:
Did the midwife provide prenatal care to a client(s) in Arkansas? *
Yes No Unknown
Did the midwife provide labor/delivery services
outside of a hospital in Arkansas? *
Yes No Unknown
Did the midwife accept payment for any services provided? *
Yes No Unknown
Description of Complaint

Describe in detail what the midwife has done or failed to do that may violate the Rules and Regulations Governing the Practice of Licensed Lay Midwifery in Arkansas. Include who, what, when and where. Client names may be given in a complaint to a Licensing Agency without violating the client’s confidentiality or HIPAA Rules. If reporting a conviction, give the name of the court, e.g., Municipal Court of ___, Circuit Court of ___, Federal Court of ___.
Describe the complaint
Do Not Fill This Out

Wufoo

Witness Information

Please answer each question below:

Description of Complaint