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PRINTED: 04/14/2016 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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How to fill out and state licensure survey

01

Obtain the state licensure survey form from the appropriate licensing board.

02

Read the instructions on the form carefully to understand what information is required.

03

Fill out all sections of the survey form accurately and completely.

04

Ensure all supporting documentation and required fees are included with the survey form.

05

Submit the completed survey form and all necessary documentation to the licensing board by the specified deadline.

Who needs and state licensure survey?

01

Individuals who are seeking professional licensure in a specific state.

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What is and state licensure survey?

State licensure survey is a survey conducted by the state licensing board to gather information about the professional activities of licensed individuals.

Who is required to file and state licensure survey?

All individuals holding a professional license in the state are required to file the state licensure survey.

How to fill out and state licensure survey?

The state licensure survey can typically be filled out online through the licensing board's website. It may require information about your professional activities, continuing education, and any disciplinary actions.

What is the purpose of and state licensure survey?

The purpose of the state licensure survey is to ensure that licensed professionals are practicing within the scope of their license and are meeting the continuing education requirements.

What information must be reported on and state licensure survey?

Information such as professional activities, continuing education completed, any disciplinary actions taken against the licensee, and contact information may need to be reported on the state licensure survey.

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