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Iowa Board of Nursing

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



Nurse Being Reported by their Employer

Home Address

Employer Address (Number & Street)

Date of Incident

Date Picker

Name from Employer who is registering this 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.

Employer Complaint

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:

¨  Incident report/Investigative report

¨  All correspondence with nurse being reported on this matter

¨  Witness statements

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

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

¨  Relevant medication withdraw/count records

¨  Relevant copies of prescriptions from physicians

¨  Relevant policies regarding this concern

¨  All corrective action/discipline forms for nurse being reported

¨  Dates of employment for nurse being reported

¨  All relevant drug/alcohol tests

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

¨  Any other relevant records

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