Peer and Practice Assessment - Pre-Assessment Information and Conflict of Interest Declaration

Peer and Practice Assessment - Pre-Assessment Information and Conflict of Interest Declaration

The purpose of this form is to provide the College with the most current information about you and your practice, and to allow you to declare a conflict of interest with potential assessors. The information will allow the College to mach you with an appropriate assessor and familiarize the assessor with you and your practice prior to the assessment. If you have any questions about this form, please e-mail qa@collegeofnaturopaths.on.ca. At the end of this form, you will be asked to enter your e-mail address for a second time. This will enable the on-line system to send you a copy of your submission details. It is recommended that you provide this information so that you will have a copy of your submission for your records.

Registrant Contact Information

Please provide the following contact information.

First Name*

Last Name*

Street Address*

Please enter the street address of your PRIMARY practice location, including any suite or unit number.

City*

Please enter the city of your PRIMARY practice location.

Postal Code*

Please enter the postal code of your PRIMARY practice location

Registration Number*

Please enter your College registration number.

Preferred Telephone*

Please provide the telephone number that you would like the College and Assessor to use for all peer and practice assessment calls. To change the flag of the country, please click the arrow next to the flat.

Phone

Email*

Please provide a valid email address to use for all peer and practice assessment e-mail communication.

Pre-Assessment Information

Please review and answer each question about your practice.

Preferred Language for the Peer and Practice Assessment.*

English

French

Practice Structure*

Sole Practitioner

Group Practice with other NDs only

Multidisciplinary practice

Teaching Clinic

Telpractice only

Home visits only

Telepractice and home visits only

Not involved in clinical patient care or have a non-clinical term, condition, and limitation

Non-Clinical Practice Description

You have indicated that you are not directly involved with clinical patient care or have a non-clinical term, condition and limitation. Please describe the work you do as a naturopathic doctor.

Have you chosen to focus or restrict your practice (e.g. modalities, demographics etc.)?*

Yes

Description of Focus or Restrictions*

Please describe the area(s) of focus or the restrictions you have placed on your practice.

Future Changes*

Do you foresee any significant changes in your practice in the next 6-12 months?

Yes

Description of Changes*

Please describe the changes you foresee in the next 6-12 months.

Controlled Acts.*

Do you perform controlled acts in your practice?

Yes

Types of Records*

Please indicate which types of records you use.

Hand written

Electronic

Electronic Patient Records Software

Please indicate the software you use for your electronic patient records.

Language of Patient Records*

English

French

Declarations of a Conflict of Interest

There is the possibility that a potential assessor and the Registrant selected to undergo a peer and practice assessment may have had some form of contact with one another. Minimal or collegial contact between the assessor and Registrant 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 assessor's professional, personal or financial relationship to the Registrant may affect their judgment or the discharge of their duties on behalf of 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.

Conflict of interest Details

As you have indicated that you have a conflict of interest with one or more of the assessors, for each assessor, please provide the details of the nature of the conflict of interest.

Declaration and Signature

Please read the declarations and signature information carefully.

Declaration

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

Signature and Date

This form will be dated with the date and time you submit it to the College. By checking the box below, you are hereby affixing your signature to this document. This replaces a manual signature because the form is submitted electronically.

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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