PROCEDURAL/OMISSION APPEAL FORM

Appealing Party's Information

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First Name-MI-Last Name:

Staff Involved:

Appeal Grounds: See directions below.

You must list supporting evidence for each ground you are appealing.
If you leave ground blank, it will not be considered.

Ground 1: A procedural error or omission occurred that significantly impacted the outcome of the process (e.g. material deviation from established procedures). This field is required.

Ground 2: To consider new evidence, unavailable during the original investigation or adjudication, that could substantially impact the original finding or sanction. A summary of this new evidence and its potential impact must be included. NOTE: When a party fails to provide a statement/evidence (e.g. under advice of counsel/advisor) during an investigation, and subsequent to the interview/hearing decides to provide the statement/evidence, it will not be considered “new evidence” for the purposes of this ground. Additionally, subsequent findings of a criminal or civil court (e.g. dismissals, plea bargains, settlements) alone do not constitute sufficient grounds for appeal, but may be considered if new evidence was the grounds for said finding. This field is required.

Ground 3: A conflict of interest or bias by an investigator, coordinator, or Administrative Hearing Panel (AHP) member that substantially impacted the outcome of the investigation or adjudication. NOTE: Parties have the ability to address an investigator’s, coordinator’s, or AHP member’s potential conflict of interest or bias for or against a given party at the time of notification of the individual’s involvement in the case. Therefore, in the appeal, the party must also explain why the party did not exercise this opportunity at the time the investigator, coordinator, or AHP member’s name was disclosed. This field is required.

List any other facts that support your appeal of this ground

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Select copy recipients

Dr. Steve Taylor

Appealing Party's Information

Appeal Grounds: See directions below.

List any other facts that support your appeal of this ground

Select copy recipients

Submission