Employer Mandatory Reporting Form
This form is used by an employer to fulfill their mandatory reporting obligations under section 57 of the Health Professions Act. The information will be treated as a complaint in accordance with section 57(2)(b).
Your Name
*
First Name
Last Name
Personal Pronouns
How you would like the College to refer to you in communication where a pronoun is normally used, e.g., she, he, they. Optional.
Your Position or Title
*
Position or Title
Name of Employer
*
Employer Name
Address where it is appropriate to receive mailed correspondence related to this reported incident.
Street Address
Street Address Line 2
City
Province
Postal Code
Your Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address
*
example@example.com
Communication
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 below. If you select no, we will send all correspondence to your mailing address.
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.
*
Yes
No
Physiotherapist Details
Physiotherapist's Name
*
First Name
Last Name
Physiotherapist's Registrant Number
Registrant number
Report Details
This is a report of:
*
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.
Reason for the Action
*
Unprofessional conduct
Incapacity
Incompetence
Sexual Abuse
Sexual Misconduct
Female genital mutilation
Detailed Description
*
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Acknowledgements
I understand that:
*
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.
Submission
Signature
*
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