Regulated Member Mandatory Reporting Form
To fulfill mandatory reporting obligations under section 127.2(1) of the Health Professions Act
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Telephone Number
*
Format: (000) 000-0000.
Email Address
Regulated Profession
*
Please Select
Acupuncturist
Audiologist
Chiropractor
Dental Assistant
Dental Hygienist
Dental Technologist
Dentist
Denturist
Dietitian
Hearing Aid Practitioner
Laboratory and X-ray Technologist
Licensed Practical Nurse
Medical Diagnostic and Therapeutic Technologist
Medical Laboratory Technologist
Midwife
Naturopath
Nurse
Nutritionist
Occupational Therapist
Optician
Optometrist
Osteopath
Paramedic
Pharmacist
Pharmacy Technician
Physician Assistant
Physician, Surgeon
Physiotherapist
Podiatrist
Psychiatric Nurse
Psychologist
Respiratory Therapist
Social Worker
Speech-Language Pathologist
Name of your regulated profession.
Patient Information
Is the patient aware you are reporting this incident?
No
Yes
Has the patient consented to you giving the College of Physiotherapists of Alberta their name and contact information?
No
Yes
Patient's Name
First Name
Last Name
Patient's Contact Information
You MUST provide one way for the College to contact the patient, either mailing address, telephone number, or email address.
Patient's Mailing Address
Street Address
Street Address Line 2
City
Province
Postal Code
Patient's Telephone Number
Format: (000) 000-0000.
Patient's Email Address
Physiotherapist Details
Physiotherapist's Name
*
First Name
Last Name
Location of Incident - Facility Name
Name of clinic, hospital, or care facility
Location of Incident - Address
Street Address and City
Report Details
This is a report of:
*
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.
Detailed Description
*
Description of information in your possession that resulted in this mandatory report.
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Acknowledgements
I understand that:
*
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.
Submission
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