Section 1 of 1 in this document

Quarterly Report - Worksite Monitor

Participant's Name:

Worksite Monitor Name & Credentials:

Worksite Monitor's Contact Information:

Indicate which quarter this report covers:

1st Quarter: January - March (due 4/20)

2nd Quarter: April - June (due 7/20)

3rd Quarter: July - September (due 10/20)

4th Quarter: October - December (due 1/20)

How often are you meeting with the participant?

Daily

Weekly

Monthly

Quarterly

Please list the date(s) you met with the participant:

Have you noticed any changes in the participant's attendance?

Yes

Have you noticed any changes in the participant's personal habits or general appearance?

Yes

Have you noticed any changes in the participant's practice performance?

Yes

Are you aware any changes in the participant's interpersonal relationships?

Yes

Have you noticed any changes in the participant's social behavior?

Yes

Have you noticed any indications of substance use?

Yes

Please provide an explanation for your responses above:

Are you aware of any successes the participant experienced this quarter? Please explain.

Are you aware of any challenges the participant experienced this quarter? Please explain.

Do you have any other concerns about the participant? Please explain.

Do you have any concerns about the participant's ability to remain in active practice without affecting public safety? Please explain.

To the best of your knowledge, have any changes or restrictions been applied to the participant's ability to practice in their workplace?

Would you like the IPHP staff to contact you?

Yes

Any further comments or questions?

Your Signature:

First Name

Last Name

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