Public Complaint Form - SSMLT | Saskatchewan Society of Medical Laboratory Technologists

Public Complaint Form

Complete the Complaint Form. Please ensure all required fields have been answered.
Please note: Anonymous complaints cannot be submitted or investigated.
Once your complaint has been received, the SSMLT will open a file and send you an acknowledgment.

By completing the formal complaint form, you:

1. Acknowledge that you are lodging a written formal complaint and understand that it is the policy of the Regulator to investigate all written formal complaints; and

2. Give permission to the Regulator to conduct a recorded interview with the Investigator; and

3. Give permission to the Regulator to release your name, any named witnesses and share some or all the information and copies of documents that it receives from you, and any other person to:

The MLT named in the complaint (respondent) as needed only

SSMLT Investigator

SSMLT Registrar

Counselling & Investigation Committee

Discipline Committee; and

4. Certify that the details and information provided are true, accurate and complete to the best of your knowledge; and

5. Disciplinary hearings are open to the public. It may be necessary to disclose your personal information (name, content of your complaint, etc.) during a hearing, should your complaint be referred to the Discipline Committee.

If you have any questions, require assistance, or would like to speak with SSMLT before completing the Complaint Form, please contact the office at 306-352-6791 or email: exec.dir@ssmlt.org

Contact Information

Date *

First Name *

Last Name *

Cell Number

Phone Number

Email *

Address

Address Line 1 *

Address Line 2

City *

Country *

Province/State *

Province/State

Postal/Zip *

Complaint Information

If you do not know the name of the MLT in question, please enter "UNKNOWN" in the first and last name fields.

MLT First Name *

MLT Last Name *

Relation to MLT *

Name of facility or location accused employed

Date of the Incident (if applicable)

Please describe the event/concern.
What happened?
Include the names of the people involved. Please provide as much detail as possible. *

List of witnesses or persons of knowledge and the contact information (if possible)

Please read and agree to the following terms

The SSMLT may provide the member with a copy or summary of the complaint and may share some or all the information and documentation collected during the investigative process. *

I understand and accept

I agree to allow for a recorded interview with the Investigator *

I understand and accept

I understand the SSMLT investigation process HERE *

I understand and accept

Please attach any supporting documentation here. (PDF or DOC file format only - each file should not exceed 2MB)

Attachement 1

Attachement 2

Attachement 3

Attachement 4

Attachement 5

OUTCOME OF COMPLAINT

What is your expectation bringing this complaint to conclusion? (1000 characters max)

I ACKNOWLEDGE that it is the policy of the Saskatchewan Society of Medical Laboratory Technologists (the Regulator) to investigate all formal complaints. I understand and accept by submitting this Complaint Form that I am lodging a formal complaint which the Regulator will investigate.

ACKNOWLEDGEMENT* *

I ACKNOWLEDGE

I CONSENT to the use of the information contained in this Complaint Form by the authorized recipient, the Saskatchewan Society of Medical Laboratory Technologists, its affiliates, and employees, who are relieved of any responsibility of liability resulting from use of the information. I give permission to the Regulator to discuss and/or release part or all of the Complaint Form and all supporting information to any person(s) named in the complaint, or any person(s) deemed necessary in the investigation of the complaint. I confirm that all details and information provided herein by me are true, accurate and complete to the best of my knowledge.

CONSENT* *

I CONSENT

Signature (type name here) *

Date complaint submitted *