You must have JavaScript enabled to use this form. This form may take up-to 30 minutes to fill in; you need to complete the form in one go, as currently, there is no option to save progress and return to finish the form later. Your details This section is about you, the person reporting the concern. If you are reporting a concern for someone else, we will ask you for their details (or the details of their parent or guardian, if they are under 18 years-old) later in the form Important: You do not have to give us your name or contact details if you do not want to. However, if we cannot contact you and we can’t confirm the information you have given us in any other way, we may not be able to investigate your concern. Let us know your name Full name Liaising with you We will usually contact you by email. Please give us your email address below, or let us know if you would prefer us to only contact you via phone or post. How would you like us to contact you? Email address Post Phone Help Please select above the best way for us to get in touch with you. Email address Help We will send you an email to let you know when we have received your concern. We will also use this email address for correspondence about your concern unless you would prefer to be contacted by phone or post. Postal address line 1 Address line 2 Town Postcode Phone number What time of the day is best for us to call you? Help Please let us know when would be best for you. For example, ‘before 10am’, ‘after 5pm’ or ‘not on Tuesdays or Wednesdays’. Are you: (This is required.) - Select -A member of the publicA pharmacist or pharmacy technician?A pharmacy owner or employer?A GP or other healthcare professional?A member of another professional body? Please Specify (This is required.) Are you an employee who is raising a concern about your employer? (This is required.) Yes No Communication needs Do you have any specific communication needs? (This is required.) Yes No Please give us details. Help Include details of anything we might be able to do that will make it easier for you to deal with us. We will consider all reasonable suggestions. If you have questions or difficulties with filling in the form please call us on 020 3713 8000. Type of concern See below the most common types of concerns we investigate. Click on the 'Help' tip at the bottom of the list for more details on what these common types refer to. Select as many that apply to help us identify the issue that best matches the concern you would like to report. Type of concern Serious unprofessional or inappropriate behaviour Dispensing errors Criminal conduct Dishonesty or fraud Working under the influence of drink or drugs Having a health condition that affects the ability to practise safely Practising while unregistered Other Help Serious unprofessional or inappropriate behaviour: Pharmacy professionals must show respect for other people and maintain proper professional boundaries. We will investigate cases where a pharmacy professional is responsible for bullying or harassment. Dispensing errors: A dispensing error could include out-of-date medication, or incorrect packaging and labelling. Criminal conduct: A pharmacy professional may have received a caution or conviction for something unrelated to their work as a pharmacist. We still need to know about this. Dishonesty or fraud: Dishonesty could cover a lot of issues, for example theft or claiming sick pay when working at the same time. Fraud could include wrongly claiming money from the NHS or other bodies. Having a health condition that affects the ability to practise safely: We may need to investigate whether a pharmacist is able to practise safely if they have a health condition affecting the way they work. Practising while unregistered: Pharmacy professionals must be included on the GPhC’s register to legally carry out their duties. If you believe that a person has been practising as a pharmacist or pharmacy technician and they are not registered, please let us know. What is your concern about? (This is required.) A pharmacist or a pharmacy technician (pharmacy professional) A pharmacy Both a pharmacy and a pharmacy professional Help A pharmacy professional is a pharmacist or pharmacy technician who is registered with the GPhC. For more information on the work of pharmacists and pharmacy technicians, please go to What does a pharmacist do? or What does a pharmacy technician do? A pharmacy could mean a particular pharmacy store or a whole pharmacy business. The pharmacy professional Do you know the name of the pharmacy professional involved? (This is required.) Yes No, but I know their registration number Not sure A pharmacy professional is a pharmacist or a pharmacy technician who is registered with the GPhC. To determine whether a person is registered with the GPhC, you can check our register (opens on a separate window). Pharmacy professional’s name Pharmacy professional’s registration number Help This is the 7-digit number which shows that a pharmacy professional is on the GPhC’s register. Search our register (opens on a separate window) to find out a pharmacy professional’s registration number. Please give us as much information as you can that might help us identify the pharmacy professional Help Do you know their name or part of their name? What did they look like? The pharmacy Please use our register (opens on a separate window) to find the full details of the pharmacy. Pharmacy name (This is required.) Address line 1 (This is required.) Address line 2 Town (This is required.) Postcode Your concern Please describe the incident, including the name of any medication involved, if that is relevant. If you are able to, please attach any evidence in relation to your concern. This can be done on the next page of the form (This is required.) Help Give details of what happened and how it affected you. Was it one incident, or several incidents over a length of time? Please give details of any evidence you have to support your concern - for example: ‘I have an apology letter from the pharmacy and a photograph of the incorrect medication’. Please keep these as we may need to see them as part of our investigation. The date the incident took place (This is required.) Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2011201220132014201520162017201820192020202120222023 Year The time the incident took place (if known) Hour01234567891011121314151617181920212223 Hour :Minute00153045 Minute If there was more than one incident please tick here Multiple incidents The date the incident took place (2) Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2011201220132014201520162017201820192020202120222023 Year The time the incident took place (if known) (2) Hour01234567891011121314151617181920212223 Hour :Minute00153045 Minute The date the incident took place (3) Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year2011201220132014201520162017201820192020202120222023 Year The time the incident took place (if known) (3) Hour01234567891011121314151617181920212223 Hour :Minute00153045 Minute Where did the incident take place? Help Did it happen in a pharmacy? Where in the pharmacy did it happen? Did anyone else see or hear the incident? Yes No Tick this box to indicate if there was more than one witness. We will ask you for their details at a later stage. Multiple witnesses Was any harm caused as a result of the incident? (This is required.) Yes No Help This might include side effects, having to get further medical treatment, or having your treatment delayed. Please give details and describe the effects the incident had on you and your health. (This is required.) Help Please describe the side effects, including: how long they lasted, their effect on you, whether there have since been any medical complications as a result. Has the pharmacy professional given you any explanation? (This is required.) Yes No Please give details (This is required.) Has the issue been sorted out? (This is required.) Yes No Please give details of how the issue was sorted out (This is required.) Has the pharmacy professional given you any advice since the incident? (This is required.) Yes No Please give details (This is required.) Did you, or the person you are reporting this for, get any medical advice or treatment? (This is required.) Yes No Please give details. (This is required.) Have you contacted anyone else about your concern? (This is required.) Yes No Who else have you contacted about your concern? The pharmacy professional The pharmacy owner or manager The head office of the pharmacy The hospital involved A GP or other doctor A local health authority Medicines and Healthcare products Regulatory Agency (MHRA) Other (please give details below) Help The MHRA regulates all medicines and medical devices in the UK. We are likely to contact them to discuss your concern. Pharmacy professional: name Address line 1 Address line 2 Town Postcode Phone number Email address Please give details about what happened as a result (This is required.) The pharmacy owner or manager: name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) The head office of the pharmacy: name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) The hospital involved: name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) A GP or other doctor: name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) Local health authority: name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) MHRA: Contact name Address line 1 Address line 2 town Postcode Phone number Email address Please give details about what happened as a result (This is required.) Other contact: name Address line 1 Address line 2 Town Postcode Phone number Email address Please give details about what happened as a result (This is required.) Is this person aware that you are giving their details to the GPhC and that we may contact them? Yes No Reporting concerns for someone else Are you reporting this concern for someone else? (This is required.) Yes No What is your relationship to this person? (This is required.) - Select -colleaguefriendGP or treating doctorlegal representativefamily memberother healthcare professionalno relationship Do you have this person’s authority to act for them? (This is required.) Yes No If not, please tell us why (This is required.) Help For example, is the person a child or a vulnerable person? Please give their name and contact details If the concern relates to a child under 18 years old, this may be the details of the parent or guardian. Name (This is required.) Address line 1 (This is required.) Address line 2 Town (This is required.) Postcode (This is required.) We may have some questions about the concern, or we may need to give you updates about what is happening if a case is opened. Please let us know who would be best to contact with this information. Who should the GPhC contact with any questions or updates about this concern? You The person named above If you are reporting a concern for someone else, and have asked for us to communicate with you about it, please remember to upload a letter of consent signed by that person. This could be an email or other document. Otherwise we will contact the other person. What is the best way to contact them? (This is required.) Mobile Land-line phone Email Post Land-line phone number (This is required.) Mobile number (This is required.) Email address (This is required.) Is there a time of day which is best for us to phone them? Help Please let us know when would be best for them. For example, "before 10am", "after 5pm" or "not on Tuesdays or Wednesdays". Communication preferences Does this person have any specific communication needs? (This is required.) Yes No Please give details Help Include details of anything we might be able to do that will make it easier for them to deal with us. Does the person have a disability which may affect their ability to communicate or receive information from us? We will consider all reasonable suggestions. Leave this field blank Continue to next page >
