Professional Conduct Reporting Form

1
Your Name* This field is required.Your first and last name. If you do not have a last name then enter a period [ . ] in the last name field.
First Name
Last Name
2
Personal PronounsHow you would like the College to refer to you in communication where a pronoun is normally used, e.g., she, he, they.
Optional.
3
Your AddressAddress where you can receive mailed correspondence.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Your Telephone Number* This field is required.Telephone number where you can be contacted during the day.
Please enter a valid phone number.
5
Your Email AddressThe College's preference is to send all correspondence by email.
example@example.com
6
I agree to receive all communication related to this report, including notices that I am entitled to under Part 4 of the Health Professions Act, via the email address provided.* This field is required.The College's preference is to send all correspondence by email. However, if email is not an acceptable way to communicate with you, please indicate no. If you select no, we will send all correspondence to your mailing address.
YESNO
7
Date of BirthProvide only if you are the patient AND the incident(s) took place in a hospital or other public facility. Your date of birth is required so the College can obtain your physiotherapy treatment record.
Date of Birth
Year
Month
Day
8
Physiotherapist's Name* This field is required.Use the College’s Verify a Physiotherapists search function, if necessary, to find or confirm the physiotherapist’s name. https://cpta.alinityapp.com/client/publicdirectory
First Name
Last Name
9
Location of Incident - Facility Name* This field is required.
Name of clinic, hospital, or care facility
10
Location of Incident - Facility Address* This field is required.
Street Address and City
11
Date(s) or date range of incident(s)* This field is required.
Date or date range
12
What Happened?* This field is required.Describe in detail what the physiotherapist did or did not do that has caused you to report this incident to the College. What resulted from this situation? Please be specific to the physiotherapist named in this report.
Huge
Large
Normal
Small
Ok
Ok
13
File UploadOptional. Upload any physical evidence related to this incident (e.g., document, picture). There is no need to provide a copy of the patient's treatment or financial records as the College will obtain these directly. You will also have the option to provide any physical evidence in your possession when you meet with the investigator.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
File upload
Cancelof
14
I understand that:* This field is required.
The College of Physiotherapists of Alberta will determine if it has jurisdiction to investigate this reported incident.
15
I understand that:* This field is required.
If the College of Physiotherapists of Alberta determines it has jurisdiction, this reported incident will be processed as a complaint in accordance with the Professional Conduct section of the Health Professions Act.
16
I understand that:* This field is required.
If the College of Physiotherapists of Alberta determines it has jurisdiction, the physiotherapist named in this report will receive a copy of this report.
17
Signature* This field is required.
Powered by Jotform SignClear
Should be Empty: