Dental, Pharmacy, Professional Licensing Quarterly Report - Worksite Monitor

Quarterly Report - Worksite Monitor

Participant's Name:

Worksite Monitor Name & Credentials:

Worksite Monitor's Contact Information:

Indicate which quarter this report covers:

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

How often are you meeting with the participant?

Daily

Weekly

Monthly

Quarterly

Dates of Meetings:

Are you aware of any changes in the participant's attendance?

Yes

Are you aware of any changes in the participant's personal habits or general appearance?

Yes

Are you aware of any changes in the participant's practice performance?

Yes

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

Yes

Are you aware of any changes in the participant's social behavior?

Yes

Are you aware of any changes in the participant's prescription/non-prescription drugs and/or alcohol?

Yes

Please provide an explanation for your responses above:

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

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

Do you have any 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, has the licensee had any restrictions to their practice and/or changes in their practice that may be affected by their impairment? Please explain.

Would you like the IPHP staff to contact you?

Yes

Any further Comments, Questions or Concerns?

Your Signature:

First Name

Last Name

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