[State of Iowa] 1 INAP Self Report

Welcome to the Iowa Nurse Assistance Program (INAP) Online Self Report system.
To begin the self-report process licensees need to submit a complete set of forms including the following:

Self-Report form
Intake Information
Release of Information
Fact Sheet

Once you complete the self report form you will be redirected to the next form required to be completed. Each form will be submitted and saved even if you do not complete all four forms. INAP is unable to process a self-report without the required forms. All forms are available on the Board website if you do not complete the process at one time. Self reports should be accurate and comprehensive. This is a confidential and secure online system. Please contact INAP at 515-725-4008 if you have any questions about the self-reporting processing.

Thank You

Note: Use the Tab key or your mouse to move from one field to the next. Using the Enter Key will cause you to exit the form.

Fill out this form thoroughly and provide details.

Submit a copy of your substance use and/or mental health (co-occurring diagnosis) evaluation if you have one.

If you have not had a co-occurring evaluation, you will need to have one completed to be considered for INAP.

Personal and Licensure Information

Date Picker

Phone Number

Alternative Phone Number

License Held in Other States

Status of Iowa Nursing License

Does INAP have your permission to contact you at the above provided addresses and phone numbers?

Yes

If no, please specify

Are you currently being investigated by the Iowa Board of Nursing?

Yes

If yes, please explain:

Has any action ever been taken against you by the Iowa Board of Nursing or any other state Nursing Board?

Yes

If yes, please explain:

Section One: Employment Information

Are you currently employed as a nurse?

Yes

If yes, please provide immediate nursing supervisor/employer, contact name, and address:

Have any of your nursing employers ever submitted a complaint against you to the Board?

Yes

If yes, please explain:

Please provide the name and contact information if working at a non-nursing job:

Is your employer aware of your self-report to INAP?

Yes

Section Two: Healthcare Provider and Treatment Information

Please provide the name and contact information of any provider prescribing medications:

Please list ALL medications you are currently taking and the name of the prescribing doctor.

Have you been evaluated by a professional for substance use or mental health?

Yes

If yes, provide the name and contact information:

Have you received treatment for substance use or mental health?

Yes

If yes, please provide treatment dates and name of address of treatment provider (doctor, psychiatrist, etc.):

Have you received ongoing care for substance use and or mental health?

Yes

If yes, please provide the name and address of aftercare provider (counselor, therapist, etc.)

Please provide the name and address of your medical provider:

Section Three: Entry Information

Some licensees may not be eligible for the INAP program. If you answer YES to any of the questions on the following page, please contact INAP before submitting this form.

Did you divert drugs to third parties for profit?

Yes

Did you adulterate/misbrand or tamper with drugs intended for patients?

Yes

Did you provide inaccurate, misleading, or fraudulent information or fail to fully cooperate with INAP?

Yes

Did you participate in the program or similar program offered by other states without success?

Yes

If you answered yes to any of the above items, please explain:

Are you a participant, or have you been a participant in another state’s monitoring program?

Yes

If yes, provide details including: dates of participation, reason for enrollment, and disposition of your case. Attach additional documents, if necessary, at the end of this form.

Please provide the details of why you are seeking entry into INAP. Be thorough and submit a detailed account. Attach additional documents, if necessary, at the end of this form.

If you need to attach additional documentation you can upload files here:

Click Here to Upload

All information submitted to the Iowa Nurse Assistance Program regarding individual licensees is confidential.

Do you give INAP permission to inquire about the facts provided in this self-report?

Yes

Additional Information

I understand that the terms of the nurse licensure compact may affect my ability to practice in another state on a compact license while participating in this program.
I understand I should not practice nursing in any other compact party state without first obtaining authorization from that party state.
I have read and understand the INAP Fact Sheet and am aware of program requirements.
I have completed the INAP intake form and submitted it.
I have completed and signed the release of information form.
I certify that all the information that I have provided is true and correct to the best of my knowledge.

NOTE: Effective 09/01/2022, The Iowa Nurse Assistance Program (INAP) participates in the Pilot Study of Nurses in Substance Use Disorder Monitoring Programs Established on Evidence Based Guidelines through the National Council of State Boards of Nursing (NCSBN). The overall aim of the proposed research is to determine whether nurses in SUD monitoring programs using NCSBNs evidence based guidelines improves successful program completion. Please be advised that the INAP provides de-identified statistical data to this study. The identity of the individuals in this study will not be made available.

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