Self Reporting Form for Members

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1. As you prepare to complete this Self-Reporting Form, if you are uncertain about the meaning of one of the reporting reasons listed below, click the “Check this box to complete Reason [Number] questions” to review notes about the meaning and intent of that reason. If that reason does not apply to you, you can unclick the check box and move on.
3. When you submit this form a copy will be emailed to you for your record.
2. The College will review the information and you will receive a separate email confirmation that your self-report is received.
4. The College will correspond with you via email and we may contact you for additional information.

PERSONAL INFORMATION

Name (Prefix, First & Last)*

Prefix First Name Last Name

RO number (Practice Permit)*

Mailing Address (street address, city, province, postal code)*

Street Address Address Line 2 City Province Postal Code

Telephone (Preferred)*

Email*

Confirm Email*

REASONS FOR SELF REPORTING

Reason One: I am a regulated member of more than one regulatory college, and another regulatory college has issued a decision of unprofessional conduct regarding my actions. Reference: HPA s.127.1(1)

Check this box to complete Reason One questions

Notes:

For the purposes of this form, this refers to regulatory colleges and licensing bodies other than paramedicine, both in Alberta and outside of Alberta.
“Decision” refers to a decision made by a Hearing Tribunal or similar panel, committee, or decision-making body. The name of the decision-making body may differ depending on the jurisdiction and legislation in place.

Please provide a copy of the decision as well as the following information. If a section is not applicable, enter N/A.

(a) In which jurisdiction was the decision made? (e.g., province, state, etc.)*

(b) What is your other regulated health profession? (E.g., RN, PT, LPN, MD, R.Psych, etc.)*

d) If there is any other information you deem relevant, please enter it here.*

The decision must be uploaded in this form (see upload section below).

Reason Two: I am a member of a governing body of a similar profession in another jurisdiction, and that body has issued a decision that my conduct as a regulated member in that other jurisdiction constitutes unprofessional conduct. Reference: HPA s.127.1(2)

Check this box to complete Reason Two questions

Notes:

For the purposes of this form, “similar profession” refers to all possible paramedicine designations such as EMT, EMR, PCP, ACP, and CCP.
“Decision” refers to a decision made by a Hearing Tribunal or similar panel, committee, or decision-making body. The name of the decision-making body may differ depending on the jurisdiction and legislation in place.

Please provide a copy of the decision as well as the following information. If a section is not applicable, enter N/A.

(a) In which jurisdiction was the decision made? (e.g., province, state, etc.)*

(b) What is your paramedicine professional designation at this governing body? (e.g., PCP, etc.)*

(d) If there is any other information you deem relevant, please enter it here.

The decision must be uploaded in this form (see upload section below).

Reason Three: I am a regulated member of the Alberta College of Paramedics and am reporting a finding of professional negligence made against me. Reference: HPA s.127.1(3)

Check this box to complete Reason Three questions

Notes:

A finding of professional negligence can only be issued by a court of law. An employer or other regulatory body cannot make this finding.

Please provide a copy of all court documents connected to the finding, as well as the following information. If a section is not applicable, enter N/A.

(a) In which court and jurisdiction was the decision made? (e.g., province, state, etc.)*

(b) What was the date of the findings?

The court decision showing the finding of professional negligence must be uploaded in this form (see upload section below).

Reason Four: I have been charged with a criminal offence under the Criminal Code (Canada). Reference: HPA s.127.1(4)

Check this box to complete Reason Four questions

Please provide the following information. If a section is not applicable, enter N/A.

(a) What criminal offence have you been charged with and what is alleged to have happened? (can provide high level details, e.g., assault, theft of X under/over $Y, harassment, etc.)*

(b) In your opinion, is there any connection to your professional role as paramedic?

Yes

If yes, please explain

(d) Where was this alleged to have happened? (include city, province, and general setting, e.g., home, workplace, public place such as coffee shop, store, etc.)*

(e) When is your projected initial court date, if known?*

(f) If there is any other information you deem relevant, please enter it here.

Upload a copy of the formal court charge sheet/criminal information sheet (see upload section below).

Reason Five: I have been convicted of a criminal offence under the Criminal Code (Canada). Reference: HPA s.127.1(4)

Check this box to complete Reason Five questions

Please provide the following information. If a section is not applicable, enter N/A.

(a) For what criminal offence were you convicted?* (provide high level details)

(b) What sentence/sanctions were imposed as a result of the conviction?*

Yes

If yes, please explain

(d) On what date were the charges filed against you?

(e) On what date were you convicted?

(f) If there is any other information you deem relevant, please enter it here.

Upload a copy of any decision, conviction documents, or court documents connected to the conviction (see upload section below).

Reason Six: I am experiencing a physical, cognitive, psychological and/or emotional condition, which includes active substance abuse, that may negatively impair my ability to practice or that is reasonably likely to impact my work in the future. Reference: Standard of Practice 1.4 Self- reporting; Code of Ethics 4.4

Check this box to complete Reason Six questions

Please provide the following information. If a section is not applicable, enter N/A

(a) Please provide details as to the nature of the physical, cognitive, psychological and/or emotional condition and the impact that it is having on your ability to practice or work now or in the future, including any limitations or restrictions you have arising from the condition.*

(b) How long have you been facing these issues?*

(d) Are you working with a health care professional to address these issues (e.g., addictions or mental health counsellor or psychologist, medical doctor, etc.)?**

(e) What treatment plans or supports do you currently have in process for this issue?**

(f) Are you taking any medications which may impact your ability to provide safe and competent care? If yes, please explain which medications you are taking.*

(g) Have you taken a leave of absence from work, and if yes, on what date did the leave begin?

Yes

Date

(h) Are you working with WCB for these issues?**

(i) Is your employer aware of your incapacity? If you are currently not employed, please indicate that.*

(j) Please provide any other information you consider relevant.*

Upload any pertinent information below (see upload section below)..

Reason Seven: I have engaged in a sexual relationship with a patient or have engaged in sexual abuse or sexual misconduct involving a patient. Reference: Standard of Practice 1.4 Self-reporting; Code of Ethics 4.4

Check this box to complete Reason Seven questions

Notes:

For the definition of Patient, please review Standard of Practice 2.4 Defining Patient-Provider Relationship access here.
For the definitions of sexual abuse and/or sexual misconduct, please refer to Standard of Practice 2.7 Sexual Abuse and Sexual Misconduct Involving a Patient access here.

(a) Please provide details regarding the nature of the relationship and conduct that you engaged in, as well as details of the patient care that was provided, as per the definitions noted in the Standards of Practice referenced above.*

(b) If there is any other information you deem relevant, please enter it here.

UPLOAD RELEVANT DOCUMENTS

Upload a copy of any/all:

decisions;
findings of professional negligence;
criminal charge/criminal information sheets;
conviction documents;
or court documents to this form.

Ensure the image or PDF uploaded is of high quality and is easily legible.

Drop files here or

Max. file size: 25 MB.

AFFIRMATION & SIGNATURE

I affirm that the information submitted here is true and correct to the best of my knowledge.

Today's Date*

Signature

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