Mandatory Licensed Health Professional Reporting Another Licensed Health Professional

Licensed Health Professional Reporting Alleged Violations by Another Licensed Health Professional to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For Professional I am Reporting

Prefix

First Name

Last Name

Middle Initial

Suffix

Profession

License Number

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Reporting Party Information

Prefix

First Name

Last Name

Middle Initial

Suffix

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Preferred method of contact:

Do you wish to remain anonymous?

Yes

List all persons present at time of incident that would have first-hand knowledge of the incident.

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Patient/Client Associated with Report

Prefix

First Name

Last Name

Middle Initial

Suffix

Date of Birth:

Primary Phone

Alt Phone

Address:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.

Attach any additional documentation.

Allowed file extensions: .tiff, .tif, .pdf, .doc, .docx, .jpg, .jpeg, .png and .gif
Max file size allowed: 20 MB.

The statements I have made are true and correct to the best of my knowledge. By signing this form, I am agreeing to the submission of this complaint by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on a complaint.

Please sign by typing your name below.

Date

11/21/2024

Public Health Investigations

Department of Health and Human Services

Division of Public Health
Investigations - Healthcare Professionals and Occupations

Mandatory Licensed Health Professional Reporting Another Licensed Health Professional

Licensed Health Professional Reporting Alleged Violations by Another Licensed Health Professional to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For Professional I am Reporting

Physical Address

Mailing Address

Reporting Party Information

Physical Address

Mailing Address

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.

Mandatory Licensed Health Professional Reporting Another Licensed Health Professional

Licensed Health Professional Reporting Alleged Violations by Another Licensed Health Professional to the Division of Public Health – Investigations Unit.

State of Nebraska Department of Health and Human Services, Division of Public Health Office of Professional & Occupational Investigations P.O. Box 94722, Lincoln, Nebraska 68509 PHONE: 402-471-0175 FAX: 402-742-8335 EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For Professional I am Reporting

Physical Address

Mailing Address

Reporting Party Information

Physical Address

Mailing Address

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov