Fitness to Practice Disclosure Form

Fitness to Practice Disclosure Form
Fitness to Practice Reporting Form
Are you a current registrant of the College?*

YesNo
What is your name?*

First NameLast Name
Phone Number*
Email*
Do you know the name of the registrant?

YesNo
Did you know?

Anyone who believes that a medical radiation technologist (MRT) or electroneurophysiology technologist (ENP) has not provided care in a competent and professional manner can make a complaint to the Complaints Director of the College.

Click here to read more.
Name of registrant*

First NameLast Name
ACMDTT #*
Name of Clinic/Hospital*
Date of incident*

MonthDayYear
Email*
Date of initial impairment*

MonthDayYear
Summary of the Fitness to Practice Disclosure
Summary of the Fitness to Practice Concern
Is the issue temporary or permanent?*

TemporaryPermanentOther
Provide a brief description of the concern.*
Any limitations and restrictions to practice?*
Are you following a recommended treatment plan?*
Do any medications related to this matter affect your ability to provide safe, competent care?*
Medical documentation to support your Fitness to Practice (if any)

pdf, doc, docx, jpg, jpeg, png
Cancelof
Supporting Documents (if any)

pdf, doc, docx, jpg, jpeg, png
Cancelof
Currently practicing?*

YesNo
Is your Supervisor/Manager/Employer aware of your fitness to practice issue?*

YesNoOther
Has this issue prevented you from meeting your CCP requirements? If so, please provide more details.*
Signature*

Clear
Date of submission*

MonthDayYear
Date
Should be Empty:

Fitness to Practice Disclosure Form

Fitness to Practice Reporting Form

Did you know?

Summary of the Fitness to Practice Disclosure

Summary of the Fitness to Practice Concern