AMEDDApplicantWorksheet-July2012-3.doc

Explanation are you the only living child in your

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Explanation: Are you the only living child in your immediate family? 14. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed Forces of the United States? Explanation: 15. Have you ever been required to appear before a medical or state regulating authority, regardless of the result, concerning your health status as an impaired, hindered, or otherwise restricted practitioner? Doctor’s Last Name: Street address, City, State, Zip Code, Country: Country Code: Telephone No.: ( ) - Extension: Explanation: 16. Have you ever had a license to practice health care profession denied in any state? 17. Have you ever had a license to prescribe narcotics voluntarily or involuntarily refused, revoked, suspended, or denied or have you ever voluntarily surrendered a license to prescribe narcotics? Explanation: 18. Have you ever had professional privileges denied, withdrawn, or restricted by any health care facility? 19. Have you ever been asked to resign from a facility or organization staff or professional society? 20. Have you ever been denied membership or renewal or been subject to disciplinary procedures in any health care organization? 21. Do you currently have Malpractice Insurance? 22. Have you ever had Malpractice Insurance (other than current Malpractice Insurance)? 23. Are you currently a defendant in a Malpractice Claim? 24. Have you ever been a defendant in a Malpractice Claim (other than current Malpractice Claim)? Include question number and continue explanations below for all ‘YES’ answers that may apply: 11
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MORAL SCREENING QUESTIONNAIRE Report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad. List all involvement with any agency if you have ever been arrested, charged, cited, held, or detained in any way by any law enforcement agency (to include juvenile authorities, Police Officers, Sheriff, Department of Natural Resources, Fish and Game Wardens, Military Police, etc.) regardless of the disposition (whether the case resulted in no charges filed, fine, probation, dismissal, or other disposition). This includes traffic tickets. Do not list charges more than once. We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity. Y/N This Question is related to your Security Clearance.
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