Complaint Reporting Form Complaint Reporting Form Step 1 of 4 25% Complainant informationName(Required) First Last Untitled(Required) Ms Mrs Mr Dr Other Home Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is your mailing address the same as your home address?(Required) Yes No A mailing address is required, if different from your home address. It cannot be a P.O. Box. Mailing Address (if different from home address) Street Address (cannot be a P.O. Box) Company name (if applicable) City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email(Required) Best phone number for contacting you during the day (8 a.m. - 4 p.m.)(Required)Alternative phone number (optional)Consent(Required) I agree to receive all updates related to this complaint, including all notices that I am entitled to receive under Part 4 of the Health Professions Act via email (rather than registered mail). I consent to receive information from the CCOA and its representatives for the purposes of conducting this complaint.Initial(Required) Chiropractor informationNote: a copy of your complaint will be sent to this individual.Name(Required) Dr. First name Dr. Last name Clinic name(Required)Clinic address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Clinic phone number(Required) Witness information Provide the full name and contact information of any other individual(s) who may have first-hand information regarding your complaint. Please include the details of the information they may have about your complaint (e.g. other chiropractor, therapist, witness(es) who were present), as well as their addresses and telephone numbers. Note: A copy of your complaint form may be sent to these individuals. Witness 1Name First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneWitness 2Name First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneWitness 3Name First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Complaint detailsHave you attempted to resolve your complaint directly with the chiropractor involved?(Required) Yes No Have you submitted a complaint to law enforcement or any other organization?(Required) Yes No Please specify where else you have submitted a complaint (enter "N/A" if not applicable):(Required)Provide a detailed description of the complaint(s) you have against the chiropractor named. Include in your description what the chiropractor did or failed to do to cause you to submit a complaint, including: what happened where it happened; and when it happened (in chronological order). Include as much detail as possible. Provide details here:What do you hope will happen as a result of your complaint?Note: The CCOA cannot provide nor direct the chiropractor to provide financial compensationSelect all that apply:(Required) Education Apology Investigation Other If you have selected Other, please describe:Relevant documents or evidence to support your complaintIf you have any supporting documentation that will assist us in investigating your complaint: Attach copies to this form. List and give a brief description of the relevant documents you have provided below. Do NOT submit originals. Provide an item # and description of any supporting evidence:(Required)Item #Description Add RemoveUse the blue plus sign to the right of field to add more rows. Upload supporting evidence here:(Required)Accepted file types: jpg, png, pdf, Max. file size: 64 MB. Ensure documents are named using the same item # and description.Signature and Consent In accordance with Section 54(1) of the Health Professions Act, a written complaint must be signed. Any electronic signature has the same legal validity and effect as your handwritten signature on this form. I, Name(Required) First Last submit this complaint to the College of Chiropractors of Alberta. Complainant signature(Required)Date signed(Required) MM slash DD slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
