IMP3

Rebecca.Carlson@iowa.gov

400 SW 8th St, Suite E Des Moines, IA 50309-4688

515-725-3491

IMP3 Self-Report Form

Full Legal Name

Other Names Used

Address

Address or Location

Primary Phone Number

Alternate Phone Number

Email Address (where confidential message may be sent)

License/Registration Type

License/Registration Number

Please describe the reasons for this self-report

Have you undergone an evaluation for this condition?

Yes

If so, where?

Have you received any treatment for this condition?

Yes

Where did this treatment take place?

Have you engaged in unlawful diversion or distribution of controlled or illegal substances for personal gain or profit?

Yes

Are you currently under a Board of Pharmacy Order for alcohol and/or drug abuse or for another issue related to impairment?

Yes

Have you caused harm and/or injury to a patient?

Yes

Is the Board of Pharmacy currently investigating you for matters related to impairment?

Yes

Have you provided inaccurate, misleading, or fraudulent information or failed to cooperate with the Board of Pharmacy or IMP3?

Yes

All information is confidential. Do you give permission to inquire about the material facts provided in this self-report?

Yes

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