Pre-Inspection Information Form

Pre-Inspection Information Form

The Inspection Program of the College of Naturopaths of Ontario inspects the premises where compounding for or the administration of IVIT are performed.

To ensure the College has the up-to-date information regarding staff who provide IVIT services at the premises, please provide the following information.

1. NEW IVIT PREMISES INFORMATION

Please provide the following information about the premises ahead of the upcoming inspection.

Number and Street Name*

Telephone*

Please select the arrow beside the flag to change it to Canada.

Phone

2. DESIGNATED REGISTRANT INFORMATION

The designated Registrant is the naturopathic doctor who has been identified as the Registrant who is authorized to deliver and accept information on behalf of the premises. If there is only one naturopathic doctor authorized to perform IVIT procedures in the premises then that Registrant is the designated Registrant. In a premises where more than one naturopathic doctor is authorized to perform IVIT procedures in the premises one of the Registrants must be identified as the designated Registrant

Last Name of Designated Registrant*

First Name of Designated Registrant*

Registration Number of Designated Registrant*

Email address of Designated Registrant*

Telephone of Designated Registrant*

Please select the arrow beside the flag to change it to Canada.

Phone

3. NATUROPATHIC DOCTORS PRACTISING IN THE PREMISES

List the name(s) of all naturopathic doctors, including the designated Registrant, who are performing IVIT procedures at this premises. (If you require more room please email the information to inspection@collegeofnaturopaths.on.ca.)

Designated Registrant Full Name*

Designated Registrant Registration Number*

ND2 Registration Number*

ND3 Registration Number*

ND4 Registration Number*

ND5 Registration Number*

4. OTHER REGULATED HEALTH PROFESSIONALS

List the name(s) of any other regulated health care professionals who are performing IVIT procedures at the premises and the regulatory College where the professional is a member. (If you require more room please email the information to inspection@collegeofnaturopaths.on.ca.)

Health Care Professional 1 - Full Name*

Health Care Professional 1 - Regulatory College*

Select

Health Care Professional 1 - Registration Number*

Health Care Professional 2 - Full Name*

Health Care Professional 2 - Regulatory College*

Select or enter value

Health Care Professional 2 - Registration Number*

Health Care Professional 3 - Full Name*

Health Care Professional 3 - Regulatory College*

Select or enter value

Health Care Professional 3 - Registration Number*

Health Care Professional 4 - Full Name*

Health Care Professional 4 - Regulatory College*

Select or enter value

Health Care Professional 4 - Registration Number*

Health Care Professional 5 - Full Name*

Health Care Professional 5 - Regulatory College*

Select or enter value

Health Care Professional 5 - Registration Number*

5. NON-REGULATED STAFF

List the name(s) of any staff who are not regulated health care professionals and are involved in providing some aspect of patient care related to the performance of IVIT procedures at the premises. Include information regarding the person’s qualifications, credentials, training and responsibilities (If you require more room please email the information to inspection@collegeofnaturopaths.on.ca.)

Please indicate the number of non-regulated staff who are providing services related to the performance of IVIT procedures in this premises.*

If there are more than 3, please provide all of the necessary information for the additional staff in an email to inspection@collegeofnaturopaths.on.ca

Non-Regulated Staff - Full Name*

Non-Regulated Staff -Qualifications, Credentials, Training.*

Non-Regulated Staff - Responsibilities*

Non-Regulated Staff 2 - Full Name*

Non-Regulated Staff 2 - Qualifications, Credentials, Training*

Non-Regulated Staff 2 -Responsibilities*

Non-Regulated Staff 3 - Full Name*

Non-Regulated Staff 3 - Qualifications, Credentials, Training*

Non-Regulated Staff 3 -Responsibilities*

6. DECLARATION AND SIGNATURE

By checking this box, you are making the following declaration.I hereby declare that, to the best of my knowledge, the information provided on this form is true and complete. I understand and agree that it may be professional misconduct to make a false or misleading statement.

I so delare*

I agree that by checking the box below, I am affixing my electronic signature to this form. In so doing, I am indicating that the form has been completed by me and that the information contained on the form may be bound to me.

Signature*

7. 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

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