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Department of Inspections, Appeals, & Licensing

6200 Park Ave. Des Moines, IA 50321


Iowa Practitioner Program Self-Report Form


Questions regarding the Iowa Practitioner Program and reporting requirements should be directed as follows:

Dental Licensees:
Other Licensees:

Please review the following definitions before completing the form.

The Iowa Practitioner Program (IPP) is a confidential monitoring program for licensees with impairments.

Impairment” means an inability, or significant potential for inability, to practice with reasonable safety and skill as a result of alcohol or drug abuse, dependency, or addiction, or any mental or physical disorder or disability. For the purposes of this program, “impairment” does not include sexual dysfunction, sexual addiction, sexual compulsivity, paraphilia, or other sexual disorder.


"Self-report" means the licensee providing written or oral notifications to the board that the licensee has received or may receive a diagnosis as having an impairment before the board's receiving a complaint or report alleging an impairment before the date of self-report.

Full Name

Dynamic Lists

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Home Address

Work Address

Date of Self-Report

Date Picker

Have you undergone an evaluation for this condition?

Have you received treatment for this condition?

Board rules specify that the following circumstances may make licensees/registrants ineligible to participate in the Iowa Practitioner Program.

  • The practitioner is engaged in the unlawful diversion or distribution of controlled substances or illegal substances to a third person or for personal profit or gain;
  • At the time of the self-report, the practitioner is already under board order for an impairment or any other violation of the laws and rules governing the practice of the profession;
  • The practitioner has caused harm or injury to a patient;
  • There is currently a board investigation of the practitioner that concerns serious matters related to the ability to practice with reasonable safety and skill or in accordance with the accepted standards of care;
  • The practitioner has been subject to a civil administrative or criminal sanction, or ordered to make reparations or remuneration by a government or regulatory authority of the United States, this or any other state or territory or a foreign nation for actions that the committee determines to be serious infractions of the laws, administrative rules, or professional ethics related to the practice of dentistry, dental hygiene, or dental assisting;
  • The practitioner provided inaccurate, misleading, or fraudulent information or failed to fully cooperate with the board or committee; or
  • There is currently a complaint before the board related to an impairment.

Do any of the items from the list above apply to you?

All of the information in the possession of the Iowa Practitioner Program (IPP) and it's personnel regarding licensees and registrants is confidential.  Do you give the IPP permission to inquire about the material facts you have provided in this self-report? 

Permission to Inquire

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If you have additional questions or concerns, please call 515-725-4112.

confirmation of self-report

You will be provided with a confirmation of self-report upon submission.