Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Initial Report

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POD-1 (09/2011)
MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE
PROFESSIONAL ORGANIZATION DISCIPLINARY ACTION INITIAL REPORT
Complete all pages of this report and mail it to the Board. Attach additional pages as necessary.
For further information, refer to the Instructions and List of Basis Codes, which are available on
our website at: Please type or print legibly. This Report must
be filed within 30 days of the disciplinary action.
For further information, please refer to Instructions. Please type or print legibly.
Physician/Provider Information
Name: _______________________________________________________________
License number: ___________________
Professional Organization Information
Organization name: ____________________________________
Telephone: _____________________
Report Completed by: ___________________________Title: __________________________
Action Taken
1. Date of disciplinary action: ____________ 2. Date report completed: ____________
3. Term(s) of disciplinary action are currently (circle one): a. Fulfilled b. Continuing
4. Expected or actual total duration of disciplinary action is (circle one):
1. Less than 30 days
2. Between 30 – 90 days
3. Between 91 - 180 days
4. More than 180 days
5. Permanent
6. Pending
7. Other
5. Nature of action(s) taken (circle each that applies):
01 Revocation of right/privilege
06 Non-renewal of right/privilege
12 Leave of absence
02 Suspension of right/privilege
09 Education/training/counseling/monitoring
13 Withdrawal of application
03 Censure
10 Denial of right/privilege
14 Termination/non-renewal of contract
04 Written reprimand/admonition
11 Resignation
98 Other (explain below)
05 Restriction of right/privilege
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