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.*

Loss or voluntary limitation of privileges

Resignation from staff

Loss of employment

Membership lost

Professional liability

Credential denied or disciplined

Court conviction

Self-Reporter's Information

Date the above action occurred:

Date of incident that led to 1, 2, or 3 above:

Name of person investigating or acting on privileges or employment:

Name of facility:

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Facility Name incident occurred, if different:

Facility Address incident occurred, if different:

Professional Liability Report

I had a professional liability claim that resulted in an adverse judgment, settlement, or award, including settlements made prior to suit; OR

My professional liability insurance coverage has been canceled, limited, or otherwise modified due to a professional liability claim: OR

I have been refused professional liability insurance coverage on an initial or renewal basis due to a professional liability claim.

Case number:

Date(s) on which the act(s) or omission(s) which gave rise to the action or claim occurred:

Date of judgment, settlement, or award:

Date of Payment:

Amount:

Name of court or adjudicative body:

Address Line 1

Address Line 2

City

State

Zip Code

Name of insurer, employer, other person, or entity making payment of the claim:

Address Line 1

Address Line 2

City

State

Zip Code

Name of patient, client, or other person to whom or for whose behalf payment was made:

Address Line 1

Address Line 2

City

State

Zip Code

Name of location or where act(s) or omissions(s) occurred:

Address Line 1

Address Line 2

City

State

Zip Code

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

I was denied a credential or other form of authorization to practice by a state, territory, or other jurisdiction, including any military or federal jurisdiction, due to alleged:

Incompetence

Negligence

Unethical or unprofessional conduct

Physical, mental, or chemical impairment

Other

I had disciplinary action taken against a credential or other form of permit by another state, territory, or jurisdiction, including any federal or military jurisdiction, or I had a settlement of such action, or I voluntarily surrendered or had a limitation placed on my credential or other form of permit.

I lost my privileges in a hospital or other health care facility due to alleged:

Incompetence

Negligence

Unethical or unprofessional conduct

Physical, mental, or chemical impairment

Other

Name of board, association, organization, or jurisdiction taking action:

Address Line 1

Address Line 2

City

State

Zip Code

Date action taken:

Date action effective:

Duration of action:

I was convicted of a misdemeanor or felony in Nebraska or another state, territory, or jurisdiction, including any federal or military jurisdiction. (Do not report speeding or parking tickets.) Include copy of conviction.

Name of Court/Jurisdiction:

City

State

Zip Code

Date of conviction:

Case Number:

Under appeal? To: (Court)

Name of crime for which convicted:

Reason for Self-Report

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

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

4/26/2024

Public Health Investigations

Department of Health and Human Services

Division of Public Health
Investigations - Healthcare Professionals and Occupations

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.

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.

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