Medical School Verification Ua Form 2 Iowa Board Of Medicine (Page 2 of 2) in pdf

Applicant Name:

___________________________________________________________________________________________

1. Do the official records for this individual reflect (an) interruption(s) or extension(s) in his/her medical education? Yes

If yes, please select the reason(s), indicate the dates of the interruption(s) or extension(s), and indicate whether the interruption(s)/

extension(s) was/were approved or unapproved.

From Month/Year

To Month/Year

Approved Unapproved

Personal/Family

___________________

Academic remediation

___________________

Health

___________________

Financial

___________________

Participation in joint degree program

___________________

(e.g., MD/PhD)

Participation in non-research special study

___________________

(e.g., fellowship, international experience)

Other: ____________________________

___________________

2. Do the official records for this individual reflect that he/she was ever placed on academic or disciplinary probation during his/her

medical education? Yes

If yes, please select the reason(s) for the probation, indicate the date(s) of placement on and removal from probation, and attach

documentation/information of the circumstances and outcome(s).

From Month/Year

To Month/Year

Academic probation

___________________

Probation for unprofessional conduct/behavioral reasons

___________________

Probation for other reason(s) (please specify):

___________________

_______________________________________________________________________________________________________

3. Do the official records for this individual reflect that he/she was ever disciplined for unprofessional conduct/behavioral reasons by

the medical school or parent university? Yes

If yes, please attach documentation/information of the circumstances and outcome(s).

4. Do the official records for this individual reflect that he/she was ever the subject of negative reports for behavioral reasons or an

investigation by the medical school or parent university? Yes

If yes, please attach documentation/information of the circumstances and outcome(s).

5. Do the official records for this individual reflect that there were ever any limitations or special requirements imposed on the individual

because of questions of academic incompetence, disciplinary problems, or any other reason? Yes

If yes, please attach documentation/information of the nature of the limitations or special requirements.

I CERTIFY THAT to the best of my knowledge and belief, the foregoing is a true, accurate, and complete statement of the

record of the individual named on this form.

Signature: ________________________________________________

Print name: _______________________________________________

AFFIX INSTITUTIONAL SEAL HERE

Title: _____________________________________________________

(If no seal is available, this form must be notarized.)

Date: ____________________________________________________

Phone number: _________________ Fax number: ________________

Email: ____________________________________________________

Uniform Application for Physician State Licensure

DO NOT SEND THIS FORM TO FCVS/FSMB.

Medical School Verification Form

11/2014

Refer to the left sidebar to determine where to mail this form.

Page 2 of 2

Medical School Verification Ua Form 2 Iowa Board Of Medicine Page 2

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