amanda.woltz@dia.iowa.gov
6200 Park Ave., Ste. 100 Des Moines, IA 50321
515.281.6674
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
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:
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 FSSolutions?
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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