IPHP Confidential Self-Report Form
To begin the self-report process, please complete this form and  provide as much detail to the Professional Health Program as possible. Please do not exit the form until it is complete and you reach the submit button. 

**This form will not be shared with anyone outside the Professional Health Programs** 
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Date Completing Self-Report Form *
MM
/
DD
/
YYYY
Which Iowa Professional Health Program (IPHP) are you self-reporting to? *
Full Name *
i.e. Joe Smith
Date of Birth
XX-XX-XXXX
Home Address *
Include City & State
Phone Number *
Format: ###-###-####
Alternative Phone Number *
Format: ###-###-####
Email Address *
Do you prefer to be contacted at your phone number or alternative number or email? *
Are you currently licensed in any other states? *
If YES, please provide a list of states.
General Reason for Self-Report *
Required
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