RETURN TO:
IMPORTANT NOTICE: This state agency is requesting
disclosure of information that is necessary to accom- ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
plish the statutory purpose as outlined under 225 of ENFORCEMENT ADMINISTRATION UNIT
the Illinois Compiled Statutes 60/23. Disclosure of Mandatory Report File Custodian
this information is REQUIRED. Failure to provide 320 West Washington Street
any required information shall result in a Class A Springfield, Illinois 62786
Misdemeanor.
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CLINICAL TRAINING PROGRAM
MEDICAL MANDATORY REPORT
MEDICAL DISCIPLINARY BOARD
GENERAL INSTRUCTIONS
The program director of any post-graduate clinical training program shall report to the Medical Disciplinary
Board if a person engaged in a post-graduate clinical training program at the institution, including, but not limited
to, a residency or fellowship, separates* from the program for any reason prior to its conclusion.
Reports must be filed with the Medical Disciplinary Board in writing within 60 days after the separation of the
licensed individual.
This report contains two parts.
Part 1 seeks basic information concerning the person making the report, the licensed individual who is the
subject of the report, and the post-graduate clinical training program.
Part 2 seeks specific information concerning the separation of the licensed individual from the
post-graduate clinical training program.
Both parts must be filled out completely. Where requested, identify and attach explanatory documentation
which will be helpful to the Medical Disciplinary Board in determining whether further investigation is warranted,
except that no medical records may be revealed without the written consent of the patient.
The law requires that this report be kept strictly confidential. All communications regarding this report should be
addressed only to authorized persons.
The law further provides that any individual or organization acting in good faith, and not in a willful and wanton
manner, in complying with this law by providing any report or other information to the Board, or assisting in the
investigation or preparation of such information, or by participating in proceedings of the Board, shall not, as a
result of such actions, be subject to criminal prosecution or civil damages.
* "Separation", as used in this Section, means any absence from a post-graduate clinical training program exceed-
ing 45 days, whether continuous or in the aggregate, in any 365 day period; any suspension from a post-graduate
clinical training program, regardless of length or reason; or any termination from a post-graduate clinical training
program. Separation includes a program's decision not to renew a person's contract to participate in the program
prior to the conclusion of the full term for which the person was originally engaged. Separation does not include
approved leaves of absence for training, maternity or paternity leave, or vacation, sick or personal leave.
IL486-2271 6/16 (MDB)
CLINICAL TRAINING PROGRAM
MEDICAL MANDATORY REPORT
Official Use Only
PART 1 – BASIC INFORMATION Code Mandatory Report Number
1.5 MR --
A. SOURCE OF INFORMATION – (Individual making report)
NAME (Last, First, MI):
PROFESSIONAL TITLE AND/OR JOB TITLE:
ADDRESS:
Street Address City State ZIP Code
TELEPHONE NO.: EMAIL ADDRESS:
Include Area Code
B. PROGRAM INFORMATION – (Institution operating the program)
CLINICAL TRAINING PROGRAM:
NAME OF HEALTH CARE INSTITUTION:
NAME OF DIRECTOR OF PROGRAM (Last, First, MI):
ADDRESS:
Street Address City State ZIP Code
TELEPHONE NO.: EMAIL ADDRESS:
Include Area Code
C. SUBJECT OF REPORT – (Individual licensed under the Medical Practice Act. Please complete a separate
report for each individual)
NAME (Last, First, MI):
ADDRESS:
Street Address City State ZIP Code
TELEPHONE NO.: EMAIL ADDRESS:
Include Area Code
PROFESSIONAL LICENSE NO.:
D. TYPE OF ACTION
Termination from Program Withdrawal from Program Leave of Absence
PART 2. – SPECIFIC INFORMATION
A. REASON FOR SEPARATION FROM PROGAM – Please provide below a comprehensive description of the reason
for the separation from the clinical program, including any act or acts with dates of any occurrences directly contributing
to the separation. (Identify and attach any appropriate documents, such as correspondence or action reports).
Date of final determination or acceptance of separation from clinical program:
Was individual in good standing upon separation of the program? Yes No
PART 3 - SIGNATURE OFFICAL USE ONLY
NAME TITLE DATE
IL486-2271
