Conduct Form - NBASLPA

Criminal Offence/Activity

1. Have you ever been found guilty of, or plead guilty to a criminal offence in Canada (defined by the Criminal Code of Canada) or similar offence outside of Canada, for which you have not received a pardon, or where there is any action pending against you?*

Yes
No

Please provide details

2. Are you currently being investigated with regards to a criminal offence in Canada (defined by the Criminal Code of Canada) or a criminal offence of a similar nature in a place outside of Canada?*

Yes
No

Please provide details

3. During the past year, have you been convicted of an offense related to the regulation of the practice of Speech-Language Pathology or Audiology?*

Yes
No

Please provide details

4. Have you received, or had ordered against you, a civil judgment (court issued order) with respect to your professional practice (i.e., negligence, breach of contract, medical malpractice, etc.)?*

Yes
No

Please provide details

Regulatory Body & Professional Conduct

5. Are you currently suspended by any regulatory body in a province or territory in Canada, or any place where you hold registration with a regulatory body?*

Yes
No

Please provide details

6. Do you currently have any conditions, terms or limitations imposed on your practice registration in any province or territory in Canada, or any place where you hold registration with a regulatory body?*

Yes
No

Please provide details

7. During the past year, have you been the subject of a finding or agreed to an admission of professional misconduct, incompetence, or incapacity that has not been reversed on appeal in New Brunswick or in another jurisdiction or any place where you hold registration with a regulatory body in relation to Speech-Language Pathology and/or Audiology or another health profession?*

Yes
No

Please provide details

8. Do you currently have any practice complaints of professional misconduct, incompetence, or incapacity filed against you in a province or territory in Canada or any place where you hold registration with a regulatory body?*

Yes
No

Please provide details

9. Are you currently the subject of a proceeding for professional misconduct, incompetence or incapacity, in New Brunswick or in another jurisdiction or any place where you hold registration with a regulatory body in relation to Speech-Language Pathology and/or Audiology or another health profession?*

Yes
No

Please provide details

If you answered YES to any of these questions, you may be contacted and requested to provide further details.

DECLARATION

1. I understand that one must hold a current certificate of registration with the New Brunswick Association of Speech-Language Pathologists and Audiologists (NBASLPA) in order to practice Speech-Language Pathology and/or Audiology in New Brunswick and that one cannot use the term “Speech-Language Pathologist” or “Audiologist” unless the person holds the corresponding certificate of registration from NBASLPA.

2. I understand that it is my responsibility to notify NBASLPA by mail, fax, or e-mail immediately of any change of name, business address (for any place of practice), business telephone number (for any place of practice), home address, home telephone number, or mailing address.

3. I understand that the business address(es) that I provide will be recorded in the Public Register so that members of the public can confirm that I have a license to practice.

I Agree*

I agree with the above statements.

By submitting this form I declare that the information provided by me is true and correct to the best of my knowledge.

Your Name*

Your Email Address*

Registration Number*