Section 1 of 4 in this document
Iowa Board of Pharmacy Quarterly Report
Full Name
First Name
*
Last Name
*
Email
*
Indicate which quarter this report covers
1st Quarter (Dec-Feb) - Due March 5
2nd Quarter (Mar-May) - Due June 5
3rd Quarter (June -Aug) - Due Sept 5
4th Quarter (Sept-Nov) - Due Dec 5
Place of Employment
*
Current Employment Status
Full-time
Part-time
Not working
Has there been a change in your employment this quarter?
Yes
No
If yes, explain
*
Are there any changes to your contact information? Include changes to name, address, phone number, or email address
Yes
No
Type of Change
*
Choose One
Name
Home Address
Home or Cell Phone Number
Email Address
Upload Name Change Document
New Information (name, address, phone number, or email address)
*
Section 2 of 4 in this document
Status of Probation Requirements
Civil Penalty
Yes
No
N/A
Status of Civil Penalty
Paid
Not Paid - not due yet
Not Paid - past due
Continuing Education (CE)
Yes
No
N/A
Status of Continuing Education
All hours complete
Not complete - not due yet
Not Complete - past due
Did you complete any CE this quarter to meet the requirements of the Board Order?
Yes
No
Attach any CE certificates for any CE completed this quarter, if required.
Evaluation
Yes
No
N/A
Status of Evaluation
Completed
Scheduled
Not scheduled - not due yet
Not scheduled - past due
Scheduled for:
Attach any evaluation completed this quarter, if required
Worksite Monitoring (ensure worksite monitor submits quarterly report, if required)
Yes
No
N/A
Has your worksite monitor changed this quarter?
Yes
No
Name of Worksite Monitor
First Name
Last Name
Treatment Provider
Yes
No
N/A
Have any of your treatment providers changed this quarter?
Yes
No
Names of Treatment Providers
*
List dates of treatment/therapy sessions
*
AA/NA Meetings
Yes
No
N/A
Attach a copy of AA/NA attendance logs for this quarter, if required
How often are you required to attend AA/NA meetings?
Never
1/week
2/week
3/week
4/week
5/week
6 or more/week
On average, how often did you attend AA/NA meetings this quarter?
Never
1/week
2/week
3/week
4/week
5/week
6 or more/week
Caduceus or Professional Meetings
Yes
No
N/A
How often are you required to attend Caduceus or Professional meetings?
Never
1/week
2/week
3/week
4/week
5/week
6 or more/week
On average, how often did you attend Caduceus or Professionals meetings this quarter?
Never
1/week
2/week
3/week
4/week
5/week
6 or more/week
Chemical Screening
Yes
No
N/A
Are you currently enrolled in FSSolutions?
Yes
No
Did you miss any check-ins this quarter? This includes late check-ins.
Yes
No
If yes, provide dates and explanations
*
Did you miss any tests this quarter?
Yes
No
If yes, provide dates and explanations
*
Do you think any of your tests were positive for a drug for which you do not have a prescription?
Yes
No
If yes, provide dates and explanations
*
Do you think any of your tests were positive for alcohol?
Yes
No
If yes, provide dates and explanations
*
Do you have a past due balance?
Yes
No
If yes, provide dates and explanations
*
List any prescriptions you are currently taking, or have taken in the last quarter, that may cause a positive result:
Other
Yes
No
Describe status/Compliance
*
Section 3 of 4 in this document
Have there been any changes in your mental health condition this quarter?
Yes
No
N/A
If yes, explain
*
Have you maintained your sobriety this quarter?
Yes
No
N/A
If no, explain
*
Have you had any patient/client complaints this quarter?
Yes
No
N/A
If yes, explain
*
Have you faced any significant professional challenges this quarter?
Yes
No
If yes, explain
*
Have you faced any significant personal challenges this quarter?
Yes
No
If yes, explain
*
Were you arrested this quarter?
Yes
No
If yes, explain
*
Do you have any requests for the Board to consider?
Yes
No
If yes, explain
*
Do you have any additional information to share with the Board?
Yes
No
If yes, explain
*
Do you have any travel plans for the upcoming quarter?
Yes
No
If yes, explain
*
I attest that I have read the Order within the last six months and understand the terms and conditions.
Yes
No
Sign Here
Sign Here
First Name
Last Name
Email
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I hereby submit this Quarterly Report as required by the Iowa Board of Pharmacy and its Order and terms of probation thereof, and declare under penalty of perjury under the laws of the state of Iowa that I have read the foregoing report in its entirety and know its contents and that all statements made are correct in every respect, and understand that misstatements or omissions of material fact may be cause for further disciplinary action.
disregard this