"Intake Form" - Iowa

Intake Form is a legal document that was released by the Iowa Board of Nursing - a government authority operating within Iowa.

Form Details:

  • Released on October 17, 2018;
  • The latest edition currently provided by the Iowa Board of Nursing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Iowa Board of Nursing.

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Iowa Nurse Assistance Program (INAP)
Offered by the Iowa Board of Nursing
400 SW 8th St, Suite B
Des Moines, Iowa 50309-4685
Phone: 515 725 4008
Fax: 515 725 4017
Email: INAP@iowa.gov
INTAKE FORM
Date: ____________________
General Information
First Name: __________________________
Last Name: ____________________________
Date of Birth: _____________________
Home Address: _______________________________________________________________
Phone Number: _______________________
Email Address: _________________________
Iowa License Number: ______________________________
License Held in Other States: ____________________________________________________
How did you hear about INAP?: _________________________________________________
Employment History
Years in Profession: ____________________
Present Employer: _______________________
Previous Employment History:
___________________________________________________________________________
___________________________________________________________________________
Information about employment discipline or termination:
___________________________________________________________________________
___________________________________________________________________________
Health History
List any substance abuse or mental health treatment (dates & diagnosis):
___________________________________________________________________________
___________________________________________________________________________
For more information about INAP or to download forms, please visit our website:
https://nursing.iowa.gov/iowa-nurse-assistance-program
Revised 10/17/2018
Page 1 of 3
Iowa Nurse Assistance Program (INAP)
Offered by the Iowa Board of Nursing
400 SW 8th St, Suite B
Des Moines, Iowa 50309-4685
Phone: 515 725 4008
Fax: 515 725 4017
Email: INAP@iowa.gov
INTAKE FORM
Date: ____________________
General Information
First Name: __________________________
Last Name: ____________________________
Date of Birth: _____________________
Home Address: _______________________________________________________________
Phone Number: _______________________
Email Address: _________________________
Iowa License Number: ______________________________
License Held in Other States: ____________________________________________________
How did you hear about INAP?: _________________________________________________
Employment History
Years in Profession: ____________________
Present Employer: _______________________
Previous Employment History:
___________________________________________________________________________
___________________________________________________________________________
Information about employment discipline or termination:
___________________________________________________________________________
___________________________________________________________________________
Health History
List any substance abuse or mental health treatment (dates & diagnosis):
___________________________________________________________________________
___________________________________________________________________________
For more information about INAP or to download forms, please visit our website:
https://nursing.iowa.gov/iowa-nurse-assistance-program
Revised 10/17/2018
Page 1 of 3
INTAKE FORM
(
)
CONTINUED
Health History
(continued)
List any substance abuse or mental health hospitalizations (dates & diagnosis):
___________________________________________________________________________
___________________________________________________________________________
List current medications:
___________________________________________________________________________
___________________________________________________________________________
Doctor prescribing medications:
___________________________________________________________________________
Psychiatric history (past & present treatments, medications, and prescribers):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Physical conditions or limitations (past & present treatments, medications, and prescribers):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Alcohol and drug history (choice, attempts at treatment, last time of use, misused medications):
___________________________________________________________________________
___________________________________________________________________________
Family/Social History
Family/social history including use of alcohol/drugs:
___________________________________________________________________________
___________________________________________________________________________
For more information about INAP or to download forms, please visit our website:
Revised 10/17/2018
Page 2 of 3
INTAKE FORM
(
)
CONTINUED
Family/Social History
(continued)
Support systems:
___________________________________________________________________________
___________________________________________________________________________
Legal History
Past or present arrests:
___________________________________________________________________________
___________________________________________________________________________
Convictions:
___________________________________________________________________________
___________________________________________________________________________
Action on licenses:
___________________________________________________________________________
Current status of professional license:
___________________________________________________________________________
Contact information for lawyer/officer, if involved:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Emergency Information
Emergency Contact’s name: _____________________________________________________
Address: ____________________________________________________________________
Phone Number(s): _____________________________________________________________
For more information about INAP or to download forms, please visit our website:
Revised 10/17/2018
Page 3 of 3
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