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 Position or Title* This field is required.

Position or Title

4

Name of Employer* This field is required.

Employer Name

5

Your AddressAddress where it is appropriate for you to receive mailed correspondence related to this reported incident.

Street Address

Street Address Line 2

City

Province

Postal Code

Country

6

Your Telephone Number* This field is required.Telephone number where you can be contacted during the day.

Please enter a valid phone number.

7

Your Email AddressThe College's preference is to send all correspondence by email.

example@example.com

8

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

9

Physiotherapist's Name* This field is required.

First Name

Last Name

10

Physiotherapist's Registrant NumberUse the College’s Verify a Physiotherapists search function, if necessary, to find or confirm the physiotherapist's registrant number. https://cpta.alinityapp.com/client/publicdirectory

Registrant number

11

Is the physiotherapist aware you are reporting this matter to the College?

YESNO

12

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

Termination

Suspension

Resignation

Grounds to believe the physiotherapist's conduct constitutes sexual abuse as defined in section 1(1)(nn.1) of the Health Professions Act.

Grounds to believe the physiotherapist's conduct constitutes sexual misconduct as defined in section 1(1)(nn.2) of the Health Professions Act.

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

13

Reason for the Action* This field is required.

Unprofessional conduct

Incapacity

Incompetence

Sexual Abuse

Sexual Misconduct

Female genital mutilation

14

Detailed Description* This field is required.Description of the incident(s) that resulted in this mandatory report.

15

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

16

I understand that:* This field is required.

The College of Physiotherapists of Alberta will provide a copy of this report to the physiotherapist as the information is treated as a complaint and processed in accordance with Part 4 of the Health Professions Act.

17

Signature* This field is required.

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