Nurse Being Reported by their Employer

License Number, if known

Email of Nurse Being Reported, if known

Home Phone

Cell Phone

Additional Information (Birthdate, Former Name, etc.)

Employer Name

Employer Phone

Date of Incident

Name from Employer who is registering this complaint:

Your Title and Credentials

Business Phone

Cell Phone Number

Relationship to Nurse

Coworker

Supervisor

Other

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

Yes

Additional Reporting Information

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First Name

Last Name

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I certify that all the information that I have provided herein is true and correct to the best of my knowledge.