Immediate registration action Schedule of undertakings for Full name of practitioner [R]

Registration number: Registration number

I, Full name of practitioner [R], am a registered registered profession in the State of Queensland under the Health Practitioner Regulation National Law (Queensland). I offer the following undertakings to the Health Ombudsman, pursuant to section 58 of the Health Ombudsman Act 2013 (the Act):

Scope of practice

Undertaking

Undertaking

Undertaking

Heading – e.g. Booking requirements

Undertaking

Undertaking

Undertaking

Heading – e.g. Employment requirements

Undertaking

Undertaking

Undertaking

Heading – e.g. Supervision requirements

Undertaking

Undertaking

Undertaking

Authorisations

Undertaking

Undertaking

Undertaking

Other matters

Undertaking

Undertaking

Undertaking

Costs

I understand all costs associated with compliance with these undertakings are at my own expense.

Definitions

The above undertakings are to be considered in conjunction with the definitions provided below.

Practitioner signature

Signature: Insert signature	Date: Click here to enter a date.

Definitions

Insert definitions here