Crystal.Walker-Smith@dia.iowa.gov
6200 Park Ave. Des Moines, IA 50321
Questions regarding the Iowa Practitioner Program and reporting requirements should be directed as follows:
Dental Licensees: Rebecca.Carlson@dia.iowa.gov Other Licensees: Crystal.Walker-Smith@dia.iowa.gov
To be completed by the IPRC participant. Please complete the following form and submit any additional comments related to this matter.
Quarterly reports are due in January, April, July & October.
Name of IPRC Participant
Work Address
Has any of your contact or employment information changed since the last report?
Please specify the quarter of review:
Does your contract require you to meet with a psychiatrist?
Does your contract require you to meet with a therapist or other aftercare provider?
Does your contract require you to have a worksite monitor?
Provide detailed information below. Note any significant changes or events since the last report. If you answer "No" or "Don't Know" to any of the following questions, provide a detailed explanation in the comments.
Note: Any changes to your contract or recovery program description must be be prior approved by the IPRC.
Since the last quarterly report, have you:
1. Been arrested, charged with or convicted of any violation of federal or state statutes or city or county ordinances, or been disciplined by a state licensing agency or board?
Response to Q1:
2. Been arrested, charged or convicted of any federal or state law pertaining to furnishing or using of narcotics or drugs?
Response to Q2:
3. Been sanctioned by a hospital, health care facility, or insurer?
Response to Q3:
4. Taken or used any controlled or prescription drugs?
Response to Q4:
5. Consumed any alcohol?
Response to Q5
6. Had any problems securing or maintaining employment or hospital privileges?
Response to Q6
7. Complied with each condition of your recovery contract?
Response to Q7
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Date Picker
Confirmation Number:
