Section 1 of 1 in this document
Licensee/Registrant Discipline Reporting Form
Licensee/Registrant Name
*
Iowa License/Registration Number
*
Iowa License/Registration Type
Resident or Nonresident Pharmacy
Wholesale Distributor
3PL
Limited Distributor
Outsourcing Facility
Nonresident Registered PIC
CSA-Individual
Iowa Licensed Pharmacist
Pharmacist-intern
Certified Pharmacy Technician
Technician Trainee
Pharmacy Support Person
CSA-Business (stand alone)
Precursor Substances
Address
Address or Location
Phone Number
*
Email
*
Contact Person (if different)
First Name
Last Name
Email for Contact Person (if different)
Phone Number for Contact Person (if different)
Jurisdiction/Agency Taking Action
*
Date of Final Action (i.e., the date the Board/licensing agency adjudicated the case)
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
Allegation/Charges
Pharmacist in charge identification, notification, etc.
Untimely renewal, license changes
Failure to report discipline
Shipping prior to licensure
Policy and procedure concerns (FDA Form 483s)
Reciprocal action
Violation of probation
Failure to report to the PMP
License revocation
License Denial
License Suspension
License Surrender
Medication/patient safety Issues
Product quality issues (FDA Warning letters, etc.)
Insanitary conditions (FDA Warning letters, etc.)
Compounding Issues
Dispensing errors
Criminal action relating to controlled substances
Allegations/Charges – provide a summary of the allegations/charges. If it was reciprocal action, provide a summary of the allegations/charges of the originating action. (DO NOT STATE “SEE ATTACHED”).
*
Outcome
Probation
Denial
Revocation
Civil Penalty/Board Assessed Fine
Suspension
Emergency Suspension
Reprimand or Censure
Voluntary Surrender
Limitation or Restriction
Cease and Desist
Provide a summary of the outcome (terms of probation, amount of citation, revocation, duration of sanction, etc.)
*
Document Upload - document(s) must be the official documents that include information about the allegations and resolution
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