Mandatory 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

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

Regulated Profession* This field is required.Name of your regulated profession.

8

Is the patient aware you are reporting this incident?* This field is required.

YESNO

9

Has the patient consented to you giving the College of Physiotherapists of Alberta their name and contact information?

YESNO

10

Patient's NamePatient's first and last name. If the patient does not have a last name then enter a period [ . ] in the last name field.

First Name

Last Name

11

Patient's Mailing AddressYou MUST provide one way for the College to contact the patient, either mailing address, telephone number or email address.

Street Address

Street Address Line 2

City

Province

Postal Code

Country

12

Patient's Telephone NumberYou MUST provide one way for the College to contact the patient, either mailing address, telephone number or email address.

Please enter a valid phone number.

13

Patient's Email AddressYou MUST provide one way for the College to contact the patient, either mailing address, telephone number or email address.

example@example.com

14

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

15

Location of Incident - Facility Name

Name of clinic, hospital, or care facility

16

Location of Incident - Address

Street Address and City

17

This is a report of:* This field is required.

I have reasonable grounds to believe the physiotherapist’s conduct constitutes sexual abuse as defined in section 1(1)(nn.1) of the Health Professions Act.

I have reasonable grounds to believe the physiotherapist’s conduct constitutes sexual misconduct as defined in section 1(1)(nn.2) of the Health Professions Act.

I have reasonable grounds to believe the physiotherapist procured or performed female genital mutilation as defined in section 1(1)(m.1) of the Health Professions Act.

18

Detailed Description* This field is required.Description of information in your possession that resulted in this mandatory report.

19

File UploadOptional. Upload any physical evidence related to this incident (e.g., document, picture).

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

I understand that:* This field is required.

The information on this form is collected under the authority of the Alberta Health Professions Act and will only be used to deal with this reported incident.

21

Submission Date* This field is required.

Date

22

Signature* This field is required.

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