Unauthorized Practice Report Form - The College of Opticians of Ontario

Information about the unregistered person(s)

Name(s) of the unregistered person(s) (if known):

Description of the individual you have concerns with (i.e., gender, height, weight, hair colour, facial features, were they wearing a badge?, etc.):*

Please provide the date(s) and time(s) of when you met with/encountered the unregistered person:*

How were you involved?*

Patient
Observer/Witness
Colleague
Former employee

How do you know this person is unregistered:*

Please provide examples of the services you received from the unregistered individual during your visit to the store, along with an explanation of why you think an unauthorized practice took place:*

(Examples of services include: eye exam, receiving prescription for contact lenses and/or glasses, fitting for contact lenses or glasses, repair or adjustment of glasses, help with choosing contact lenses or glasses, diagnosis or treatment for an eye condition, delivery of complete glasses/lenses or other)

Information about the dispensary where you believe unauthorized dispensing is taking place

Name of Dispensary/optical store:*

Mall/Plaza (if applicable):

Store Province:*

Store Address:*

Store Suite/Unit:

Store City:*

Store Postal Code:*

Store Phone:*

Hours of Operation:

Do any Registered Opticians or Optometrists work at the dispensary?*

Yes
No
Not Sure

If yes, please provide their name(s):*

Specific days/times that the Registered Optician/Optometrist are on the premises:

Specific days/times that the Unregistered person(s) are on the premises:

Please outline your concerns providing as much detail as possible, including the following:

A description of the event(s) that took place involving the unregistered person, including the reason(s) you are concerned about their conduct.
Dates of service/encounter
Please specify if the unregistered person referred to themselves as a registered optician and/or provided any opticianry services (i.e. fittings, measurements, adjustments etc.)

Upload supporting documentation (if any) with an explanation of how each document relates to your concerns:

An unauthorized practice report to the College may be filed anonymously; however, without your contact information we may not be able to follow up on information provided and/or investigate the concerns as thoroughly as possible or at all.

Therefore, we encourage the person(s) reporting unauthorized practice to provide their information, which will be used strictly by the College, should we require further information/details. The College will make every reasonable effort to protect your confidentiality.

Reporting Person(s) Information

Person #1

First Name:

Last Name:

Address:

Unit/Suite:

City:

Province:

Postal Code:

Phone:

Email:

Add another Reporting Person

Copy of your Report

If you would like to receive a copy of your report, please check the box below and enter an email address for delivery. Please note that the email address that you provide for this purpose will not be shared with the College.

Send me a copy of my responses

Email: *

Protecting the Public

Unauthorized Practice Form

Information about the unregistered person(s)

Information about the dispensary where you believe unauthorized dispensing is taking place

Reporting Person(s) Information

Copy of your Report