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Report Unauthorized Use of Title

In order to protect the public, all registered nurses practicing in Saskatchewan must be registered with the College of Lorem Ipsum (XXXX). This form allows you to report anyone you believe is carrying themselves out to be a registered nurse, a registered nurse with additional authorized practice, a registered nurse(nurse practitioner) or a graduate nurse and doesn't hold a Practicing licence.

If you have physical evidence related to your complaint, you can attach it to this form or mail it to:

XXXX Complaints & Investigation

Attn: XXXX Investigator
2066 Retallack Street
Regina, SK S4T 7X5
Email: professionalconduct@XXXX.org

Important

If you need help submitting a complaint or are having difficulty using this form, we want to hear from you. Contact us at XXX-XXX-XXXX.

All information with a ‘*’ is required information.

Your Information (Complainant)

The Individual You Are Reporting (Respondent)

Nurse (search for a nurse on the public register by name or member number)

Details of Your Report

Describe the incident(s) that took place in as much detail as you can provide, including when and where the incident(s) occurred.*

Witnesses & Additional Information

Provide names and contact information of any witnesses to the incident(s).

Provide names and contact information of anyone you told about the incident(s).

Provide any additional information related to the incident(s).

Supporting Documents

Upload File

Acknowledgement

I, as the complainant, agree to the following terms in submitting my report:*

1. The person in question will be provided an opportunity to respond to the concerns outlined in the report.
2. The XXXX may communicate with any person or persons who may be able to assist with the investigation of this report.
3. My name will be released to the person in question, the XXXX Registration & Membership Committee, the XXXX Investigation Committee, and/or the XXXX Discipline Committee for the purpose of conducting a thorough investigation.
4. I will allow for a recorded interview (audio and/or video) with a XXXX representative.