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Person Making Referral
*First Name:
Middle Name:
*Last Name:
Title:
Company:
*Street Address:
*City:

*State:

*Zip:
County:
*Email Address:
Supervisor's Name (if different from above):
Day Telephone:
*Relationship of Person Making Referral to Practitioner (Choose only one)
Employer: Self: Coworker: Family
Member: 		College/
University: 		Attorney/Law Enforcement: Other:
*Reason for Referral/Report (Check all that apply)
+UDS in Workplace Illegal Drug Use
Alcohol Impairment
Behavior (Anger Management, Disruptive), Mental Health

Other
Specify:    

Criminal Arrest/Conviction Quality of care (Charting - Patient Abandonment - Neglect)
Drug Diversion Sexual Abuse, Harassment or Contact
Eating Disorder Substance Abuse - Dependency
Forgery Unethical Conduct
Specify:  
*Work Setting (Check only one)
Hospital Office
Agency College - University - School
Nursing home - Long term care Community - public - government agency
*Practitioner Information (Subject of Referral)
*First Name:
Middle Name:
*Last Name:
Title:
Company:
*Social Security Number:
*Date of Birth:
*Street Address:
*City:

*State:

*Zip:
County:
*Home Telephone:
Mobile Telephone:
*Profession (e.g., RN, CRNA, NP, LPN, PA, OT, OTA, PT, PTA, EMT, EMT-P Medical Laboratory, Respiratory Care):
*Tennessee License Number:
 
*Details of Complaint: Please provide pertinent information, such as the sequence of events surrounding your concern in chronological order, and also provide the names of others who are aware of or who witnessed the events.

*Date(s) Above Incident(s) Occurred:

*Pharmacy Involvement:

   Yes        No

 If Yes, Name and Address of Pharmacy:
*Please Read the Following and Click the Box Below.
By checking the box below, you certify and affirm that the information provided herein is complete and accurate to the best of your knowledge:
*Required Fields