Health Care Professional’s Reporting Form
(This form is to be used only by licensed health care professionals.)
Information about Health Care Professional Submitting this Report
Name of health care professional submitting report: _________________________________________________________________
Health care professional license type: _____________________________________________________________________________
Health care professional license number: __________________________________________________________________________
Telephone number: ___________________________ (include area code)
E-mail address: ______________________________________________________________________________________________
Health care professional’s street address: __________________________________________________________________________
City ____________________________________ State __________________________ ZIP code: _________________________
Information about Health Care Professional being Reported
Last name: ____________________________________ First: _______________________________ Middle: ___________________
Type of professional license or certicate held: ______________________ License or certicate number: ______________________
(If known)
Additional Information
A health care professional shall promptly notify the division if that health care professional is in possession of information which
reasonably indicates that another health care professional has demonstrated an impairment, gross incompetence or unprofessional
conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare.
1. The health care professional has demonstrated:
impairment
gross incompetence
unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare
2. Approximate date of the health care professional’s conduct: ________________________________________________________
3. Details of the health care professional’s conduct related to impairment, gross incompetency and/or unprofessional conduct.
Signature of person submitting report: _________________________________________ Date of report: ______________________
Reports should be submitted to:
Francine Widrich, Clearinghouse Coordinator
New Jersey Division of Consumer Affairs
via fax at 973-792-4270 or
via email at widrichf@dca.njoag.gov
For information, please call 973-504-6310 or 973-896-8058.
For Ofce Use Only
Casenumber:DCA_______________________
(TobeassignedbytheDivisionofConsumerAffairs)
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