Appendix 3 — Official Referral Form

Fitness to Practise Referral Form

Use this form to report any incident of unacceptable conduct by a UKREMT registrant. Please give as much detail as possible. You should also send all supporting evidence to ftp@ukremt.org and/or direct to the auditor who sent you this form for a quicker response.

Important: If your concern involves an immediate risk of harm to a patient or member of the public, please contact the relevant statutory authorities, emergency services or safeguarding lead without delay. Do not rely solely on this form.

Section A — Details of the Registrant

The UKREMT registrant about whom you are raising a concern.

Full Name of Registrant

UKREMT PIN

Employer / Organisation

Role / Job Title

Section B — Details of the Concern / Incident

Please give as much detail as possible. Use a separate sheet or enclose an internal report if the space is not adequate.

Date(s) of Incident

Location of Incident

Description of Concern *

Include what happened, what was said or done, and why you are concerned. Use a separate sheet if needed.

Witnesses

Names and contact details of any witnesses (if known).

Supporting Evidence

List any documents, photographs, records, dashcam/bodycam footage or other evidence you are able to provide. Email copies to ftp@ukremt.org.

Section C — Your Details (Referring Person)

These details are required to process your referral and may be disclosed to the registrant as part of a fair process.

Your Full Name *

Organisation / Employer

Your Role / Job Title

Email Address *

Phone Number

Your Address

Section D — Relationship & Prior Concerns

Your relationship to the registrant

e.g. colleague, supervisor, patient, member of public, employer, other.

Have you raised this concern elsewhere?

e.g. with the registrant's employer, CQC, police, another regulatory body. If so, please give details.

Section E — Declaration

Your personal details will be held securely and used only for the purpose of processing this concern in accordance with UK GDPR and the UKREMT Privacy Policy. UKREMT reserves the right to disclose your identity to the registrant where this is necessary and proportionate to a fair process. Malicious or vexatious referrals may result in action against the referring party.

I confirm that the information provided in this form is true and accurate to the best of my knowledge, and I understand that UKREMT may contact me for further information. *

You can also submit by email to ftp@ukremt.org or by post to:

UKREMT c/o Ambulance Station, Turtle House, Cotswold Airport, Kemble, Gloucestershire, GL7 6BA