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Iowa Board of Nursing

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



Form for Nurse to Self-Report

Employer Address (Number & Street)

Details of Self-Report: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 documentation supporting the above mentioned concerns as follows but not limited to the following:

¨  Letter of explanation

¨  Criminal Court Records from Clerk of Court (Complaint/Affidavit showing charge, Plea of Guilt, Conviction, and Sentencing Order)

¨  Discipline records from other jurisdiction

¨  Signed authorization/release for substance abuse records and/or mental health records.

¨  Full comprehensive Substance use/Mental health Evaluation (usage history, diagnosis, recommendations)

¨  Full comprehensive Discharge Summary (Dates of services, further recommendations)

¨  Updated Progress Notes

¨  Witness statements

¨  Witness contact information (address, phone, email, position at facility)

¨  All relevant drug/alcohol tests

¨  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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