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State of Iowa

info@iowa.gov

200 E Walnut, Des Moines , IA, 50309, US

Welcome to the Iowa Nurse Assistance Program (INAP) Online Self Report system.

To begin the self-report process licensees need to submit a complete set of forms including the following:

  1. Self-Report form
  2. Intake Information
  3. Release of Information
  4. Fact Sheet
Once you complete the self report form you will be redirected to the next form required to be completed. Each form will be submitted and saved even if you do not complete all four forms. INAP is unable to process a self-report without the required forms. All forms are available on the Board website if you do not complete the process at one time. Self reports should be accurate and comprehensive. This is a confidential and secure online system. Please contact INAP at 515-725-4008 if you have any questions about the self-reporting processing.
Thank You
 
Note: Use the Tab key or your mouse to move from one field to the next. Using the Enter Key will cause you to exit the form.
 
Fill out this form thoroughly and provide details.

Submit a copy of your substance use and/or mental health (co-occurring diagnosis) evaluation if you have one.

If you have not had a co-occurring evaluation, you will need to have one completed to be considered for INAP.

Personal and Licensure Information

Date Picker

Date Picker

Full Name

Full Address

Does INAP have your permission to contact you at the above provided addresses and phone numbers?

Are you currently being investigated by the Iowa Board of Nursing?

Has any action ever been taken against you by the Iowa Board of Nursing or any other state Nursing Board?

Section One: Employment Information

Are you currently employed as a nurse?

Have any of your nursing employers ever submitted a complaint against you to the Board?

Is your employer aware of your self-report to INAP?

Section Two: Healthcare Provider and Treatment Information

Have you been evaluated by a professional for substance use or mental health?

Have you received treatment for substance use or mental health?

Have you received ongoing care for substance use and or mental health?

Section Three: Entry Information

Some licensees may not be eligible for the INAP program. If you answer YES to any of the questions on the following page, please contact INAP before submitting this form.

Did you divert drugs to third parties for profit?

Did you adulterate/misbrand or tamper with drugs intended for patients?

Did you provide inaccurate, misleading, or fraudulent information or fail to fully cooperate with INAP?

Did you participate in the program or similar program offered by other states without success?

Are you a participant, or have you been a participant in another state’s monitoring program?

If you need to attach additional documentation you can upload files here:

All information submitted to the Iowa Nurse Assistance Program regarding individual licensees is confidential.

Do you give INAP permission to inquire about the facts provided in this self-report?

Additional Information

  • I understand that the terms of the nurse licensure compact may affect my ability to practice in another state on a compact license while participating in this program.
  • I understand I should not practice nursing in any other compact party state without first obtaining authorization from that party state.
  • I have read and understand the INAP Fact Sheet and am aware of program requirements.
  • I have completed the INAP intake form and submitted it.
  • I have completed and signed the release of information form.
  • I certify that all the information that I have provided is true and correct to the best of my knowledge.

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