PROFESSIONAL INSPECTION COMMITTEE OF THE ORDRE DES CHIROPRATICIENS DU QUÉBEC
STATEMENT OF FACTS
I, the undersigned, ______________________________, secretary of the professional inspection committee of the Ordre des chiropraticiens du Québec, hereby declare that:
(1) On the __________ day of ______________________________, you were the subject of (an inspection under the program for general supervision of the practice of the profession) (a special inquiry into your professional competence)
(2) Following that (inspection) (special inquiry), a report was drawn up on the __________ day of ______________________________. A copy of that report is attached hereto;
(3) The report on that (inspection) (special inquiry) indicates that you experience difficulties in respect of (the practice of the profession) (your professional competence), particularly as regards:
(a) ______________________________________________________________________
(b) _____________________________________________________________________________
(c) _____________________________________________________________________________
(d) _____________________________________________________________________________
(4) If you wish to be heard, you must, within 10 days following receipt of this statement of facts, request in writing that the committee hold a hearing. Failing such request, the committee may proceed in your absence, without further notice, and, where applicable, may make its recommendations to the board of directors.
In witness whereof, I have signed at ______________________________________________________
On this ______________________________ day of ________________________________________
Professional inspection committee
Per: ________________________________________________________________________________
Committee secretary