PROFESSIONAL LICENSE PROBATION COMPLIANCE REPORT

REPORT INFORMATION

SECTION 1: PROBATIONER INFORMATION

1.1 Personal Information

1.2 Probation Order Information

1.3 Address/Employment Changes

☐ No changes since last report
☐ Changes as follows:

SECTION 2: PROBATION CONDITIONS SUMMARY

2.1 Ordered Conditions

[List all conditions from probation order and current compliance status]

2.2 Overall Compliance Statement

☐ I am in full compliance with all terms and conditions of my probation.
☐ I am in substantial compliance with minor issues noted below.
☐ I am not in compliance with certain conditions as explained below.

SECTION 3: PRACTICE/EMPLOYMENT REPORT

3.1 Current Practice Status

☐ Currently practicing
☐ Not currently practicing
☐ Practicing with restrictions as ordered

Current Practice Setting:
☐ Solo practice
☐ Group practice
☐ Hospital/institutional
☐ Government agency
☐ Educational institution
☐ Other: [________________________________]

3.2 Employment Details

3.3 Practice Activities This Period

Number of Patients/Clients Served: [____]

Types of Services Provided:
[________________________________]
[________________________________]

Any Unusual Occurrences or Incidents:
☐ None
☐ Yes - described in Section 8

3.4 Practice Restrictions Compliance

If practice restrictions were ordered:

SECTION 4: SUPERVISION REPORT

4.1 Supervisor Information

☐ Supervision not required
☐ Supervision required and in effect

4.2 Supervision Activities This Period

Total Supervision Hours This Period: [____]

4.3 Supervisor's Report

☐ Supervisor report attached (Exhibit [____])
☐ Supervisor report to be submitted separately

Supervisor's Assessment Summary (if available):
[________________________________]
[________________________________]
[________________________________]

SECTION 5: CONTINUING EDUCATION/REMEDIAL TRAINING

5.1 Required Education/Training

5.2 Courses Completed This Period

5.3 Competency Examinations

☐ Examination not required
☐ Examination required

SECTION 6: SUBSTANCE ABUSE MONITORING (If Applicable)

6.1 Applicability

☐ Substance abuse monitoring not required - Skip to Section 7
☐ Substance abuse monitoring required - Complete this section

6.2 Treatment/Recovery Program

6.3 Support Group Attendance

Required Frequency: [____] meetings per week

Total Meetings This Period: [____]
Meetings Required: [____]
Compliance: ☐ Yes ☐ No

6.4 Drug/Alcohol Testing

Testing Program: [________________________________]
Testing Frequency: ☐ Random ☐ Scheduled: [________________________________]

Total Tests This Period: [____]
All Negative: ☐ Yes ☐ No (explain in Section 8)
Missed Tests: ☐ None ☐ [____] (explain in Section 8)

☐ Lab reports attached as Exhibit [____]

6.5 Abstinence Statement

I certify that during this reporting period:

☐ I have abstained from all alcohol and controlled substances except as prescribed
☐ I have taken only medications as disclosed to and approved by the Board
☐ I have not experienced any relapse

Medications Currently Taking:

SECTION 7: MENTAL HEALTH MONITORING (If Applicable)

7.1 Applicability

☐ Mental health monitoring not required - Skip to Section 8
☐ Mental health monitoring required - Complete this section

7.2 Treatment Provider Information

7.3 Treatment Compliance

7.4 Provider Report

☐ Provider report attached (Exhibit [____])
☐ Provider to submit report separately

SECTION 8: INCIDENTS AND DISCLOSURES

8.1 Required Disclosures

During this reporting period, have any of the following occurred?

8.2 Incident Details

[If any "Yes" answers above, provide detailed explanation]

Incident 1:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Incident 2:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

8.3 Non-Compliance Explanation

[If any conditions marked non-compliant, explain circumstances and remediation plan]

Condition: [________________________________]

Explanation:
[________________________________]
[________________________________]

Remediation Plan:
[________________________________]
[________________________________]

SECTION 9: FINANCIAL OBLIGATIONS

9.1 Fines and Costs

Payment This Period: $[________]

☐ Payment receipt attached as Exhibit [____]

9.2 Restitution (If Ordered)

SECTION 10: INTERVIEWS AND MEETINGS

10.1 Board/Analyst Meetings

10.2 Availability

I remain available for interviews and meetings as required by the Board.

Best Contact Method: ☐ Phone ☐ Email ☐ Either
Best Times: [________________________________]

SECTION 11: EXHIBIT LIST

SECTION 12: CERTIFICATION AND SIGNATURE

I, [________________________________], certify under penalty of perjury that:

1. I have read and understand all terms and conditions of my probation order.
2. The information provided in this report is true, complete, and accurate to the best of my knowledge.
3. I am in compliance with all terms and conditions of my probation, except as disclosed in this report.
4. I understand that failure to comply with probation conditions may result in further disciplinary action, including revocation of my license.
5. I understand that providing false information in this report may constitute a separate violation.
6. I authorize the Board to verify all information contained in this report.

_________________________________
Probationer Signature

_________________________________
Printed Name

Date: [__/__/____]

SECTION 13: SUPERVISOR VERIFICATION (If Applicable)

I, [________________________________], as the designated supervisor for [Probationer Name], certify that:

1. I have supervised the probationer as required by the probation order.
2. The information regarding supervision in this report is accurate.
3. I have no concerns regarding the probationer's practice, except as noted below.

Concerns (if any):
[________________________________]
[________________________________]

_________________________________
Supervisor Signature

_________________________________
Supervisor Name and License Number

Date: [__/__/____]

SUBMISSION INSTRUCTIONS

Submit Report To:

[Licensing Board Name]
[Attention: Probation Unit / Assigned Analyst]
[Address]
[City, State, ZIP]

Submission Methods:

☐ Mail
☐ Email: [________________________________]
☐ Online Portal: [________________________________]
☐ Fax: [________________________________]

Submission Deadline:

Reports must be received by [__/__/____].

Late submissions may constitute a probation violation.

Keep Copies:

Retain copies of all submitted reports and supporting documents for your records.

IMPORTANT REMINDERS

Reporting Obligations

• Submit reports by the deadline specified in your probation order
• Report any address or employment changes within [____] days
• Report any incidents or violations promptly (do not wait for regular report)
• Respond to all Board communications promptly

Compliance Tips

• Keep a calendar of all probation deadlines
• Document all compliance activities as they occur
• Maintain copies of all submitted reports
• Communicate proactively with your assigned analyst
• Seek clarification if any condition is unclear

Consequences of Non-Compliance

Non-compliance with probation conditions may result in:
- Citation and fine
- Extension of probation period
- Additional conditions
- Lifting of stay on suspension
- License revocation
- Reporting to national databases (NPDB)

SOURCES AND REFERENCES

• State Professional Licensing Board Probation Guidelines
• California Board of Behavioral Sciences Probation Information
• North Carolina Medical Board Compliance and Monitoring
• NPDB Guidebook - Reporting State Licensure Actions
• State Administrative Codes

This template is designed to assist licensees in documenting probation compliance. Probation requirements are specific to individual orders. Review your probation order carefully and contact your assigned analyst with any questions about compliance requirements.