Type 1 Occurrence Report

PREMISES INFORMATION

Please provide the following information about the registered IVIT premises (clinic) where the occurrence happened.

Clinic Name*

Please enter the name of the clinic at which the occurrence happened.

Street Address*

Please enter the number and street name where the clinic is located.

City*

Please enter the City in which the clinic is located.

Province*

Please enter the Province in which the clinic is located. The default has been set to Ontario.

ON

Postal Code*

Please enter the Postal Code of the clinic.

OCCURRENCE INFORMATION

Please provide the following information about the occurrence.

Type of Occurrence*

1. Death of a patient at the premises after a procedure was performed.

2. Death of a patient that occurs within the five days following the performance of a procedure at the premises.

3. Referral of a patient to emergency services within the five days following the performance of a procedure at the premises.

4. A procedure performed on the wrong patient.

5. Administration of an emergency drug to a patient immediately after a procedure was performed at the premises.

6. Diagnosis of a patient with shock or convulsions occurring within the five days following the performance of a procedure at the premises.

7. Diagnosis of a patient as being infected with a disease or any disease-causing agent after a procedure was performed at the premises, if the Registrant is of the opinion that the patient is or may have been infected because of the procedure.

Date of Occurrence*

Please identify the date that the occurrence occurred at the premises.

Occurrence Details*

Describe in detail the occurrence and the steps taken in response. Include events leading up to the occurrence, treatments given before, during and after the occurrence, other actions taken and the outcome. (If more room is required please, send additional information by email to inspection@collegeofnaturopaths.on.ca.)

PATIENT INFORMATION

Please provide the following information about the individual to whom the occurrence being reported happened.

Please enter the initials of the patient.*

DO NOT ENTER THEIR FULL NAME.

Patient Date of Birth*

Please enter the date of birth of the patient.

Sex of the Patient*

Please select the patient's sex.

Female

Male

REPORTING REGISTRANT INFORMATION

Last Name*

Please enter your last (family) name.

First Name*

Please enter your first name.

Registration Number*

Please enter your College Registration number.

E-mail Address*

Please enter your e-mail address.

Practice Address

Please enter the number and street name of your practice if it is different from the clinic information provided above.

Practice City

Please enter the city in which your practice is located if it is different from the clinic information provided above.

Practice Province*

Please enter the province in which your practice is located if it is different from the clinic information provided above.

ON

Please enter the postal code of your practice.*

Please enter the postal code of your practice if it is different from the clinic information provided above.

TREATING STAFF

List the names of all staff, naturopaths, registered health care practitioners (HCP) and non-registered health care practitioners (non-HCP), who were directly involved with providing care to the patient when the occurrence happened. (If more room is required please e-mail the additional information to inspection@collegeofnaturopaths.on.ca.).

Last Name - Treating Staff 1*

First Name - Treating Staff 1*

Status - Treating Staff 1*

Healthcare Professional

Non-healthcare professional

Last Name - Treating Staff 2

First Name - Treating Staff 2

Status - Treating Staff 2

Healthcare Professional

Non-healthcare professional

Last Name - Treating Staff 3

First Name - Treating Staff 3

Status - Treating Staff 3

Healthcare Professional

Non-healthcare professional

WITNESSES

List all of the names of those who witnessed the occurrence. If more room is required, please e-mail these details to inspection@collegeofnaturopaths.on.ca.

Witness 1

Please enter the first and last name of the first witness.

Witness 2

Please enter the first and last name of this witness.

Witness 3

Please enter the first and last name of this witness.

Witness 4

Please enter the first and last name of this witness.

Witness 5

Please enter the first and last name of this witness.

DECLARATION AND SIGNATURE

Declaration*

Do you declare that to the best of your knowledge, the information is true and complete and that you understand that it may be professional misconduct to make a false or misleading statement to the College?

Yes, I freely make this declaration.

No, I do not make this declaration.

Signature

By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.

I affix my digital signature*

SUBMISSION COPY

Below is a check box to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address for a second time. This will enable the on-line system to send you a copy of the information that you have provided to the College.

Send me a copy of my responses