Notification Form - Complaint form by lindash

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           NOTIFICATION FORM – Health and other professionals
   The purpose of this form is for doctors and other professionals to         If you provide information to the Board honestly and
   notify the Board about a doctor’s professional conduct or health.          on reasonable grounds, the protection provided to
   If you are a doctor notifying the Board about incidents of reportable      you under legislation means you will not be held
   misconduct, you can either complete this form or use it as a guide to      liable, civilly, criminally or under an administrative
   the information required when lodging a written notice.                    process, for providing that information. (Section 387-
   If you are a patient or patient representative wishing to make a           390 of the          Health Practitioners (Professional
   complaint about a doctor, please complete the Board’s Notification         Standards) Act 1999).
   Form – Patients and Patient Representatives.

   To assess notifications, the Board requires factual evidence. You are requested to provide relevant supporting information
   with this notification form, such as:
                     Patient/Clinical records
                     Reports (e.g. Incident reports, Medico legal reports)
                     Records of clinical audits
                     Names, position title, and contact details of other people present (witnesses)
                     Prescriptions, certificates, drug charts
                     Staff rosters
                     Advertisements, business cards

   Please note that the Board may not have access to information and documents held by Queensland Health.




           Please answer all questions below (where relevant) and sign the declaration

 1. Your details
                                                                                       Registration No.
  Family Name/Surname^:
                                                                                       (doctors only):

  Given Names^:

  Postal address^:

  Suburb/town^:                                                                        Postcode^:

  Telephone:                                                               Mobile:

  Email:


 2. Who is the report about?
  Family Name/Surname*^:                                                               Registration No.:

  Given Names*^:                                                                       Date of birth:         dd / mm / yyyy

  Postal address:

  Suburb/town:                                                                         Postcode:

  Telephone:                                                               Mobile:

  Email:


                                                                                                                                   1
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
  Version January 2010
 3. Mandatory Reporting
  Are you a doctor notifying the Board about another doctor’s reportable misconduct ?^                              No             Yes


  reportable misconduct, by a registrant, means—

  (a) conduct relating to the practice of the profession that would reasonably be considered to be sexual misconduct; or

  (b) practice of the profession while intoxicated by a drug or alcohol; or

  (c) practice of the profession—

       (i) while affected by a physical or mental impairment, or other health condition, other than intoxication by a drug or alcohol; and

       (ii) that causes, or is likely to cause, significant harm to a person receiving professional services from the registrant practising the
       profession; or

  (d) practice of the profession—

       (i) in a way that significantly departs from accepted standards of the profession; and

       (ii) that causes, or is likely to cause, harm to a person receiving professional services from the registrant practising the profession.’




 4. What does your report relate to?*^
  Conduct                                Documentation                        Communication                          Health
  Eg.                                    Eg.                                  Eg.                                    Eg.
      Clinical assessment                    Medical records                     Insensitive/rude/                     Mental health
      Sexual misconduct                      Access to records                   misleading/incorrect                  Substance abuse
      Medication                             Medical reports                     Consent                               Physically impairment
      Inappropriate prescribing              Medico-legal reports                Confidentiality                       Other impairment
      Inadequate/inappropriate               Certificates                        Misrepresentation
      treatment                                                                  Clinical advertising
      Assault physical/verbal
      Standard of care

  Patient access
  Eg.
      Admission                             Unconventional/                                                              Other (please specify):
                                                                                   Breach of conditions or
      Transfer                              Experimental
                                                                                   undertakings
      Discharge                             medicine                                                                 ______________________



5. What is your relationship to the doctor?
       Medical colleague                    Treating practitioner of                 Employer of the doctor                Allied health professional
       Professional Body                    the doctor                               Manager/Supervisor of              Other (please specify):
       Nurse/Midwife                        Coroner/Police/Medicare                  the doctor                      ______________________


 6. Location (if known)?
  Is your report about health services provided within Queensland?*^

  If no, please make a report to the relevant State or Territory.                                                     No             Yes
  If yes, please give details about where the incident happened.


  Practice/Facility
  Name^:

  Street address^:

  Suburb/town^:                                                                                                       Postcode:

  Telephone:

  Contact person:


                                                                                                                                                    2
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
  Version January 2010
 7. Patient details
  Is a specific patient involved? If yes, what are the patient’s details (if known)?                      No         Yes

  Family name:

  Given name/s:

  Date of birth:          dd / mm / yyyy

  Telephone:

  Email:

  Do you know if the patient has made a report to the Board?                                              No   Yes         Unsure
  Please provide details about why the patient has not made a report? (leave blank if unknown)




  Is the patient aware that you are making a report to the Board?                                         No   Yes     Unsure

  Do you know if other patients might be at risk?
                                                                                                          No   Yes
  If yes, please provide details


 8. Details of notification/health referral*^
 A. If your report relates to a clinical event, what type of medical treatment did the patient receive?




 B. When did you become aware of the conduct/health issue?^
 C. Is anyone else able to provide further information to assist with the assessment of this
                                                                                                          No   Yes         Unsure
      notification?
 If yes, please provide details (this may include the names of other medical/health practitioners)

 1.                                                                               Contact Phone No. :

 2.                                                                               Contact Phone No. :

 3.                                                                               Contact Phone No. :

 D . Please provide factual details about what happened OR if you are making a health related referral please describe the
      behaviours/situations that have led to the referral*^:




                                                                                                                                    3
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
  Version January 2010
9. Other
  Have you lodged, or do you intend to lodge, a complaint with any other agency, i.e. Health       No     Yes      Unsure
  Quality Complaints Commission (HQCC), Queensland Police, Ethical Standards Unit (Qld.
  Health)?
  If yes, please give details of which agency




10. Privacy & Confidentiality
  It may be necessary for us to send a copy of your report to the doctor for a response. Under s392 of the Health Practitioners
  (Professional Standards) Act 1999 complaint information must not be released to anyone else unless is deemed to be in the
  public interest to do so, or if the person to whom the information relates agrees to the disclosure.

  The Office of the Medical Board will only use the information collected on this form to manage your notification. In accordance
  with the Queensland Government’s Information Standard No 42 – Information Privacy (IS42), your personal information will
  not be disclosed to any other organisation without your consent unless required by law.



              I declare that the above statements are true and correct and that all documents and supporting material lodged with
               this notification form are true and correct.


  Signature:                                                                        Date:




 11. Supporting Information
  Have you attached all relevant supporting information with this form, such as:


             Patient/Clinical records                               Incident Reports
             Prescriptions, certificates, drug charts               Names, position title, and contact details of other people
             Staff rosters                                          present (witnesses)
             Advertisements, business cards                         Medico legal reports
                                                                    Other


  Once complete, this form can be sent via:

  Email: complaints@medicalboard.qld.gov.au                       Mail:    Medical Board of Queensland
                                                                           Professional Standards Unit
                                                                           GPO Box 1667
                                                                           Brisbane Qld 4001
  Fax:       07 3225 2645

  The Board thanks you for your cooperation in completing this notification form. If you need assistance, please contact our
  Client Services Officer on 07 3234 0176. The Board considers all matters raised by members of the community seriously and
  all efforts are made to deal with notifications in a timely manner. This may include referring your notification to the HQCC for
  resolution. The time taken may depend on the risk and complexity of the issues. For more information about the Board’s
  processes, please visit the Board’s website www.medicalboard.qld.gov.au to view the Disciplinary Policy.




                                                                                                                                     4
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
  Version January 2010
Appendix 1

 166 Registrant must give notice about reportable Misconduct

 (1) Subsection (2) applies if, in the practice of the profession, a registrant (the first registrant) becomes aware, or reasonably
 suspects, that another registrant (the second registrant) has engaged in reportable misconduct.

 (2) The first registrant must, as soon as practicable, give the board a written notice stating the following information—

      (a) the first registrant’s name and address;

      (b) the second registrant’s name;

      (c) details about the following—

              (i) the nature of the reportable misconduct;

              (ii) when the reportable misconduct happened, if known by the registrant;

              (iii) where the reportable misconduct happened, if known by the registrant.

              Note—
              A contravention of subsection (2) by a registrant is conduct forming the basis for a ground for disciplinary action
              against the registrant under the Health Practitioners (Professional Standards) Act 1999, section 124(1)(f).

 (3) A notice given to the board under subsection (2) is taken to be a complaint about the second registrant made under the
 Health Practitioners (Professional Standards) Act 1999, part 3.

 (4) Subsection (2) does not apply if the first registrant knows, or reasonably believes, that a written notice under subsection (2)
 about the reportable misconduct has already been given to the Board.

 (5) For subsection (1), the first registrant does not form the relevant suspicion about the second registrant in the practice of the
 profession if—

        (a) the first registrant—

              (i) is employed or otherwise engaged by an insurer that provides professional indemnity insurance that relates to
              the second registrant; and

              (ii) forms the relevant suspicion as a result of a disclosure made by a person to the first registrant in the course of
              legal proceedings or the provision of legal advice arising from the insurance policy; or Health and Other Legislation
              Amendment Bill 2009 Page 4

        (b) the first registrant forms the relevant suspicion in the course of providing advice about the reportable misconduct for
        the purposes of a legal proceeding or the preparation of legal advice; or

        (c) the first registrant is a lawyer and forms the relevant suspicion in the course of providing legal services to the second
        registrant in relation to a legal proceeding or the preparation of legal advice in which the reportable misconduct is an
        issue.

 (6) In this section—

 forms the relevant suspicion , about the second registrant, means becomes aware, or reasonably suspects, that the second
 registrant has engaged in reportable misconduct.
 harm, to a person, means any detrimental effect on the person’s physical or psychological wellbeing.’.
 reportable misconduct, by a registrant, means—

        (a) conduct relating to the practice of the profession that would reasonably be considered to be sexual misconduct; or

        (b) practice of the profession while intoxicated by a drug or alcohol; or

        (c) practice of the profession—

              (i) while affected by a physical or mental impairment, or other health condition, other than intoxication by a drug or
              alcohol; and

              (ii) that causes, or is likely to cause, significant harm to a person receiving professional services from the registrant
              practising the profession; or

        (d) practice of the profession—

              (i) in a way that significantly departs from accepted standards of the profession; and

              (ii) that causes, or is likely to cause, harm to a person receiving professional services from the registrant practising
              the profession.’.

								
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