Mandatory Licensed Health Professional Self-Reporting

Licensed Health Professionals reporting adverse action 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

Indicate the type of situation you are reporting.*

Self-Reporter's Information

Physical Address

Mailing Address

List the profession and license number for each Nebraska license, certificate, or registration held.

Profession
License Number

Patient or client name associated with this report.


Facility, Board, Association, Jurisdiction, or Hospital associated with this report.


Loss or voluntary limitation of privileges or resignation from staff or loss of employment report.





Professional Liability Report


Credential denied or disciplined, membership lost, or court conviction report.





Reason for Self-Report

Please describe the events leading to the actions noted above. Give as much detail as possible.
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.

10/7/2024