03/2019
PHYSICIAN’S NAME: ____________________________________________________________ PERMIT NO. _______________
PGT PROGRAM/FACILITY: _________________________________________________________________________________
TRAINING SPECIALITY: ____________________________________________________________________________________
C. PROFESSIONAL CONDUCT HISTORY QUESTIONNAIRE
Failure to properly answer the questions below may result in board disciplinary action or denial.
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a separate
blank sheet of paper. As appropriate, attach copies of documents from hospitals, programs, State Boards, courts
and law enforcement agencies confirming your explanation. YES NO
1.
Have you ever been arrested for, charged with or convicted of any felony, or any misdemeanor? You must answer
“yes” even if the offense occurred outside of Arizona, the case has not yet been adjudicated, you completed a
diversion program, you received a s
uspended sentence or probation, the convictions were dismissed or set aside, your
sentence was commuted, the records were expunged, your civil rights were restored or you received a pardon.
2.
Have you had any disciplinary or adverse action imposed against any professional license, or were you denied a
professional license, or have you entered into any consent agreement, stipulated order, or settlement with any
regulatory board; OR have you bee
n notified of any complaints or investigations against your license that have not yet
been resolved?
3.
Has your DEA permit or prescription permit issued by any regulatory board been denied, restricted, suspended,
lost, or had any other adverse action
taken against it, OR have you been notified of any complaints or investigations
against your authority to prescribe that have not yet been resolved?
4. Has any award, settlement, or payment of any kind been made by you or on your behalf to resolve a civil suit or
malpractice claim involving your practice even if it was not required to be reported to the National Practitioner Data
Bank; OR have you been notified that any such suit or claim is pending?
5. Have your hospital privileges or health care
program affiliations been denied, restricted, lost, suspended or
modified, or subjected to any other adverse action even if that action was not required to be reported to the National
Practitioner Data Bank; OR have you been notified of any complaints agai
nst or reviews of your privileges or
affiliations that have not yet been resolved?
6.
During an internship, residency or fellowship program were you placed on probation, had your privileges
restricted or suspended, terminated from the program or had any other adverse action taken against your
participation even if that action was not required to be reported to the National Practitioner Data Bank?
D. PROFESSIONAL CONDUCT HISTORY - CONFIDENTIAL QUESTIONNAIRE
E. I attest that I am the applicant and the person named in this application and in all materials submitted in support of this application, that
all facts stated herein as well as any facts stated on any separate sheets attached hereto are true, complete and correct. I understand any
misrepresentation, including omission of information, may result in an unprofessional conduct action against this permit or any subsequent
application for licensure.
Applicant’s Signature: ________________________________________________________ Date:_______________________
Submit your completed form and applicable documentation to your residency coordinator.
If you answer “yes” to either of the following questions, you must submit a detailed written narrative statement
concerning matter(s) including the name of the healthcare providers and treatment centers where you were
treated along with the discharge summary of your treatment and progress. If you are currently participating or
have participated in a confidential agreement or order in a program for the treatment and rehabilitation of
doctors of osteopathic medicine impaired by alcohol, drug abuse or for other issues, please submit a copy of the
agreement/order along with compliance reports from the state monitoring programs.
YES NO
1. Have you been diagnosed with or developed initial or worsening symptoms of a condition which did or may
impair or limit your ability to safely practice medicine?
2. Have you entered into a diversion program
for evaluation, treatment or monitoring for substance abuse or
dependency or for correction of communication or boundary issues, in lieu of or as a condition of resolving a matter
before a regulatory board, criminal or civil court; OR have you been notified that such action is pending? You must
answer “yes” even if you received a pardon, the convictions were set aside, the records were expunged, your civil
rights were restored and whether or not the sentence was imposed or suspended.
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