Department of Health Professions
Compliance Forms
All of the forms below are Microsoft Word documents except where noted. You can get the Microsoft® Word Viewer 97/2000 to view and print documents. For the PDF files below you'll need the free Adobe Acrobat Reader.
Self Report Forms
- Certified Nurse Aide
- Clinical Psychologist
- Dentist or Dental Hygienist
- Licensed Clinical Social Worker
- License Professional Counselor
- Nurse
- Nursing Home Administrator
- Optometrist
- Pharmacist or Pharmacy Technician
- Veterinarian or Veterinary Technician
- Other
Performance Evaluation Forms
- Supervisor Report Form - Behavioral Sciences
- Performance Evaluation Form - Certified Nurse Aide
- Performance Evaluation Form - Dentist
- Performance Evaluation Form - Nurse
- Performance Evaluation Form - Pharmacist
- Performance Evaluation Form - Pharmacy Tech
- Performance Evaluation form - Veterinarian
Miscellaneous Forms
- Drug Log for Prescribers (Excel)
- Employer Notified of Board Order
- Form #1 for Initial Contact with Compliance
- Prescriber report to Board of Drugs or Prescription given to licensee
- Recovery Support Group Attendance Log
- Chaperone Approval Request Form
Approval Forms
- Evaluator approval request
- Supervisor approval request - Behavioral Sciences
- Chaperone Fact Sheet (pdf)
- Chaperone Report Form (pdf)
- Therapist approval request
Got A Compliance Question?
Call us today -- we will be glad to help you!
Call: 804-367-4530