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PRINTED: 08/26/2024 FORM APPROVEDIllinois Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.
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What is statement of licensure violations?
A statement of licensure violations is a formal document that outlines any infractions or breaches of licensing regulations by a license holder.
Who is required to file statement of licensure violations?
Individuals or entities that hold a professional license and have experienced any licensing violations are required to file this statement with the appropriate regulatory body.
How to fill out statement of licensure violations?
To fill out the statement of licensure violations, the individual must provide personal identification information, details of the violation, dates, and any supporting documentation as required by the licensing authority.
What is the purpose of statement of licensure violations?
The purpose of the statement of licensure violations is to maintain transparency and accountability in regulated professions, ensuring that any misconduct is documented and addressed appropriately.
What information must be reported on statement of licensure violations?
The information that must be reported includes the licensee's name and contact details, the nature and description of the violation, relevant dates, and any actions taken in response to the violation.
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