Inspection Program - Registrant Conflict of Interest Declaration Form

The role of the Inspection Program of the College of Naturopaths of Ontario it to inspect premises where compounding for and the administration of IVIT are performed. The information provided in the form will help to ensure there is no conflict of interest between the inspector assigned to inspect the premises and the staff members who deliver IVIT related services.


Please direct any questions regarding this form to inspections@collegeofnaturopaths.on.ca.

PREMISES INFORMATION

Please provide the name of the registered premises.

Please provide your street number and street name, or postal box number for your mailing address.

Please provide the city, town or community for your mailing address.

Please select the Province or Territory for your mailing address.

Ontario
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Please provide the postal code for your mailing address.

Please enter the name of the Designated Registrant for this premises.

Please enter the registration number for the Designated Registrant.

CONFLICTS OF INTERESTS

There is the potential that an assigned inspector and a member of the staff (Naturopathic Doctor, other health care practitioner or other staff member) practising at a premises may have had some form of contact with one another. Minimal or collegial contact between the inspector and one or more of the staff members is acceptable and is unlikely to result in a conflict of interest.


A conflict of interest exists where a reasonable person would conclude that the inspector’s professional, personal, or financial relationship to one or more of the staff members may affect their judgment or the discharge of their duties to the College. A conflict of interest may be real or perceived, actual or potential, direct or indirect. Examples of a conflict of interest could exist with personal relationships (ongoing or in the past), professional relationships (shared practices, business arrangements, etc.), and an existing relationship where one person is in a position of authority over another. Each case of a potential conflict of interest is evaluated on its own set of circumstances.


The following section includes the names of the College’s inspectors for the Inspection Program, one of whom will be assigned to inspect the above premises. In order for the College to assign the appropriate inspector please complete this form to indicate whether or not a conflict of interest may exist.

This form is to be completed by the Designated Registrant on behalf of themself or the applicable staff member.


CONFLICT OF INTEREST DISCLOSURE(S)

The list below identifies all of the Inspectors, any of whom might be assigned to conduct the inspection of your premises.


Please check off each of the inspectors with whom a conflict of interest may exist. Check all that apply.


As this is a mandatory field, if no conflict of interest exists with any of the inspectors, please select ***NONE***.

For each of the inspectors for which you have identified a conflict of interest may exist, please provide the staff member(s) name(s) and title/role and the details of the conflict of interest for each inspector.


If there is insufficient room, please submit additional electronic forms.

Declaration*

I hereby declare that, to the best of my knowledge, the information on this form is true and complete. I understand and agree that it is professional misconduct to make a false or misleading statement.

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.


COPY OF SUBMISSION

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

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