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Iowa Board of Nursing

400 SW 8th Street, Suite B, Des Moines, IA 50309



Nurse Being Reported by Patient/Law Enforcement/Other

Employer Address (Number & Street)

Name of Patient/Law Enforcement or Other Person Registering Complaint

Relationship to Nurse

Details of Complaint: Please type the details of your complaint. Use a separate report form for each individual. Provide pertinent information such as: the chronological order of events, names of witnesses and telephone numbers, copies of documents relevant to the situation being reported.

This Board and its Investigators are authorized by Iowa Code §§ 147.55, 152.10, 152.11 and 272C.3, to investigate nurses licensed by this state for the purposes set forth in the cited statutes.   Iowa Code §272C.6(4) further ensures that protected information will be maintained as privileged and confidential to the extent of the law.  The Iowa Board of Nursing is a HIPAA exempt regulatory agency. Please forward documents that are not redacted.  

Please upload or send in any applicable documentation supporting the above mentioned concerns as follows but not limited to the following:

¨  Incident report/Investigative report or explanation of incident being reported

¨  All correspondence with nurse being reported on this matter

¨  Witness statements

¨  Witness contact information (address, phone, email)

¨  Relevant patient’s charting (MAR, Orders, Nursing Notes, etc.)

¨  Audio and video recordings depicting relevant events stated in your complaint, if available

¨  Any other relevant records

This information will be utilized only for purposes authorized by Iowa law.  This information will not be utilized for any other purpose other than stated in this request.

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Has this complaint been reported to additional governmental agencies (Law Enforcement, DIA, Medicaid Fraud, other Board, etc.)?

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