Report a Colleague

Physicians have a responsibility to uphold patient safety and to protect the integrity of the medical profession. As such, if a physician has reasonable grounds to believe that a colleague has engaged in unprofessional or unethical conduct or has provided medical care which falls below the expected standard, the physician has a legal obligation under s. 41 of the Medical Act, 2011 to report their concerns to the College.

For more information, please refer to the College's Standard of Practice - Duty to Report a Colleague and our Frequently Asked Questions.

If you are making this report as a physician leader in a role you hold within Newfoundland and Labrador Health Services, you do not need to use this form. This type of report can be made from NL Health Services to the Office of the Registrar by email to registrarsoffice@cpsnl.ca

If you have questions, please contact the Office of the Registrar at 709-726-8546 or by email, registrarsoffice@cpsnl.ca

Your Full Name*

Email*

If a patient discloses information which leads a physician to believe that another physician has engaged in conduct deserving of sanction, the physician must provide the patient with information on how to file a complaint with the College.

If the patient does not wish to file a complaint, the physician must report the information to the Registrar, only revealing the identity of the patient if they consent.

Patient's Full Name

Patient's MCP Number

Patient's Date of Birth

Physician Information

Physician's Full Name*

Where Did the Incident Take Place? (clinic, hospital, office, etc.)*

Incident Date(s)*

Description of the Incident

Please be as detailed as possible and provide information in paragraph form.

Description of the Incident/Behaviour that Concerns You*

Additional Information

If applicable, please upload any supporting documentation, that may be relevant to your report. The College's investigator may contact you if the additional information is necessary for their investigation.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Witnesses

List any people who may have information about this incident. You are not required to have a witness to make a report to the College. NOTE: Please ensure that each witness is aware that the College may contact them as part of the investigation of your report.

Witness Name

Witness Contact Info (phone/email)

Connection to the Patient/Incident

How They Were Involved

Witness #2 Name

Witness #2 Contact Info (phone/email)

Witness #2 Connection to the Patient/Incident

How They Were Involved

Declarations

I declare that the information provided in this report is true and accurate to the best of my knowledge.*

I acknowledge that I have read and understand the above statement.

I understand that circumstances may arise which would require the College to identify me as the physician who provided this mandatory report*

I acknowledge that I have read and understand the above statement.

Full Name*

Date Submitted*

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Phone

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