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Iowa Board of Pharmacy

amanda.woltz@iowa.gov

400 SW 8th St. Ste E Des Moines, IA 50309

515-281-6674

Iowa Board of Pharmacy Quarterly Report

Full Name

Indicate which quarter this report covers

Current Employment Status

Has there been a change in your employment this quarter?

Are there any changes to your contact information? Include changes to name, address, phone number, or email address

Upload Name Change Document

Status of Probation Requirements

Civil Penalty

Status of Civil Penalty

Continuing Education (CE)

Status of Continuing Education

Did you complete any CE this quarter to meet the requirements of the Board Order?

Attach any CE certificates for any CE completed this quarter, if required.

Evaluation

Status of Evaluation

Scheduled for:

Date Picker

Attach any evaluation completed this quarter, if required

Worksite Monitoring (ensure worksite monitor submits quarterly report, if required)

Has your worksite monitor changed this quarter?

Name of Worksite Monitor

Treatment Provider

Have any of your treatment providers changed this quarter?

AA/NA Meetings

Attach a copy of AA/NA attendance logs for this quarter, if required

How often are you required to attend AA/NA meetings?

On average, how often did you attend AA/NA meetings this quarter?

Caduceus or Professional Meetings

How often are you required to attend Caduceus or Professional meetings?

On average, how often did you attend Caduceus or Professionals meetings this quarter?

Chemical Screening

Are you currently enrolled in NTS?

Did you miss any check-ins this quarter? This includes late check-ins.

Did you miss any tests this quarter?

Do you think any of your tests were positive for a drug for which you do not have a prescription?

Do you think any of your tests were positive for alcohol?

Do you have a past due balance?

Other

Have there been any changes in your mental health condition this quarter?

Have you maintained your sobriety this quarter?

Have you had any patient/client complaints this quarter?

Have you faced any significant professional challenges this quarter?

Have you faced any significant personal challenges this quarter?

Were you arrested this quarter?

Do you have any requests for the Board to consider?

Do you have any additional information to share with the Board?

Do you have any travel plans for the upcoming quarter?

I attest that I have read the Order within the last six months and understand the terms and conditions.

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