Complaint Reporting Form

Complaint Reporting Form
The information provided on this form is retained securely and in accordance with our Privacy Policy. Attach any relevant information you have that will assist in this investigation.
Your Contact Information (Complainant)
Complainant's Name*

First NameLast Name
Complainant's Email (Please provide a secure and confidential email)
Do you consent the College communicating with you by secured email?*

YesNo
Complainant's Address (If you are an employer, please provide your organization’s address) *

Street Address

Street Address Line 2

CityProvince

Postal Code
Complainant's Phone Number*
Alternate Phone Number

Complaint Information
Provide the full name of the technologist involved with this complaint and the date the incident occurred. If the name of the technologist is unknown, please advise, and we will still investigate. Please note that the technologist will be receiving a copy of your complaint.
Technologist's Name

First NameLast Name
*To initiate the complaint process, it is crucial that we receive the name of the technologist involved. If you are unable to provide the name, please provide any other relevant details that might assist in identifying the individual. Please note, though your application will be accepted by the College; your application processing might be delayed without the relevant information.
Please provide a clear description of the complaint and the technologist (attach additional documentation if required). (This section must be completed in order to lodge a formal complaint.)
Date(s) of incident(s) or approximation
If you have any related documentation regarding the incident(s), please upload it.

pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, jpg, jpeg, png, gif
Cancelof
Location of incident(s) (facility name)*
Facility's Address (if available)

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number (if available)
Provide names and contact information of other individuals from whom information may be obtained (i.e. physicians, witnesses, etc.)

What do you hope will happen as a result of your complaint? Please note that the College cannot provide financial compensation. The Health Professions Act lists the available decisions and hearing tribunal sanctions that may be pursued.

By signing this form, I confirm that the details contained in my complaint submission are correct to the best of my knowledge. We cannot process your complaint if this form is incomplete; please ensure all areas are complete before submitting.
Signature*

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Date

MonthDayYear
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Complaint Information