Notification of Concern about a Healthcare Student

Submit Notification of Concern about a Healthcare Student

Important Information

Practice staff - please consider carefully whether this is an issue relating to student competence. If so it should be addressed via normal practice competency assessment strategy and in discussion with your PLT education representative.

In submitting this form you should be advised that the information provided may be disclosed to the individual concerned if requested or if used as the basis of an investigation

In submitting this form you are confirming that this is a true statement, to the best of your knowledge

Retention of data (DPA)

Forms which do not lead to any action will have the same retention as the student file.
If the raising of a concern results in Fitness to Practise hearing, your form will be retained as part of Fitness to Practise hearing paperwork.

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Please tell us the Student's Name and Course (if known)

Student's First Name (If unknown please type "Not Known") Required

Student last Name (If unknown please type "Not Known") Required

Course of Study (If unknown please type "Not Known")

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Behaviour

Please outline the nature of the concern, giving as much detail as possible including date(s) of behaviour causing concern and any witnesses

What Occured? Required

Where Did This Behaviour Occur? Required

When Did This Behaviour Occur? Required

The police / University Security have been / are involved in reviewing issues related to the concern:

If known, please include the police/security incidence number

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Please complete your Contact Details

Your First Name Required

Your Last Name Required

Please provide your full address Required

Please provide your postcode Required

Your Telephone Number

Please provide your email address

Please select the category most relevant to you, listed below

Details of 'other' type of complainant

Please Indicate how you were alerted to this concern Required

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If you have taken any action to address the behaviour which has caused concern please give details below.

If you have not taken any action, please press Submit at the bottom of the page.

Action Number	Please outline action taken	Action taken by whom	Designation	Date
1	Please outline action taken	Action taken by whom	Designation	Date

Submit Concern Notification