PERSON SUBMITTING THE REPORT:

* required information

• Last Name
  

• First Name
  

• Title or Position *
  

• Facility Name (including site) *
  

• Street Address *
  

• City *
  

• Province *
  

• Postal Code *
  

• Phone *
  

• Mobile or Pager
  

• Email *
  

• If you are not the RT’s direct supervisor, please describe your relationship to the RT.
  

RESPIRATORY THERAPIST WHO IS THE SUBJECT OF THE REPORT:

• Last Name *
  

• First Name *
  

• CRTO Registration # (if possible)
  

DETAILS OF YOUR REPORT:

• Please provide an outline of the incident/conduct. Include specific details such as date(s), time(s), location(s). *
  

• Does the incident/conduct relate to a particular patient/client? If so, you should make your best effort to inform the patient/client prior to filing your report. In cases where a patient/client may have been sexually abused, patient/client consent to disclose his/her name is mandatory; see consent form. If patient/client consent cannot be readily obtained, or is refused, please indicate this. *
  

• Patient/Client informed or consent received? YesNo

• Gender: MaleFemale

• Date of Birth (DD/MM/YYYY)
  

• Date of Death (if applicable) (DD/MM/YYYY)
  

• Last Name *
  

• First Name *
  

• Home Address
  

• City
  

• Province
  

• Postal Code
  

• Country
  

• Home Phone
  

• Mobile Phone
  

• Email
  

• Are there other people who witnessed the incident/conduct? (please provide names and contact information for each witness)

• Last Name
  

• First Name
  

• CRTO Registration #
  

• Other Regulated Health Profession

• Phone
  

• Mobile or Pager
  

• Email
  

• What actions have you or the facility taken to date to address the issue(s) with the Respiratory Therapist? *
  

• What was the Respiratory Therapist’s response to this action? *
  

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