Quarterly Declaration - California
BUSINESS, CONSUMER SERVI CES, AND HOUS I NG AGENCY-D epartment of Consumer AffairsEDMUND G. BROWN JR.,Governor
M EDICAL BOARD OF CALIFORNIA
Refer to www.mbc.ca.govfor office locations
Quarterl y Decl aration
INSTRUCTIONS: Please type or print neatly. ALL requested information and questions on this form must be answered. When space
provided i s ins uf fi cie nt, att a ch addit ion al sheets of p aper . All attachme nts are con sid ered part of th e Declarati on. You ma y w ish to make
and retain a copy of the m aterial subm itted to t he Medical Board. Mail the complete d Declaration to your assigned pr obatio n monitor. DO
NOT FAXyour Declaration. The Medical Board requires an original signature on each quarterly declaration and a faxed signature will
not be accepted.
Check Appropriat e Box for Reporting Period Covered
Reporting Period Due to the Board By
January - March (First Quarter) April 10
April - June (Second Quarter) July 10
July - Sept em ber (Third Quart er) Oct ober 10
October - December (Fourth Quarter) January 10
(Continued on reverse)
Name: First Middle Last Aliases
Home Address: Nu mber & Street City StateZip Phone Number
Primary Place of Practi ce (i nclude additi onal plac es of practice on reverse)
Address: Number & Street City StateZip P hone Num ber
Cell Phone Num ber
Indicate the number of hours worked this quarter at your primary place of
P er week Per month
What is your work schedule at this place of prac tice?
The Following Questions Refer to t he Time Period Si nce
Your Last Quarterly De cl ar ation
1.Have you violated any count y orcity ordinances, been arrested, charged, convicted of, pled nolo
cont endere in any state or federal court or foreign count ry to any misdemeanor, f el ony, or other offense?
(If yes, specify which one in your explanation. E xclude parking tickets.)
2.Have you violated, been arrest ed, convicted of, or received a citation for driving under the influence of
alcohol or drugs, reckless driving, or any ot her vehicle code violation involving alc ohol or drugs?
3.Are you required to undergo biological fluid testing by any directive other than what is in your
Order? If yes, when were you last tested and what is the frequenc y of testing?
4.Is there any governmental, civil suit, malpractice, or peer review pr oceeding pending against
5.Have you resigned from any employment or has yourem pl oym ent been terminated?
6.Are you in the process of applying for any other business or profess i onal licens e or
7.Have you had to report any theft or loss of controlled substances to the Department of
8.Have you had to report a patient death in an outpatient surgery setting pursuant to Business
and Profess i ons Code secti on 2240(a)?
9.Did you cease practici ng since your last report? If yes, give t he date you ceased practice.
10.Have you been denied, had a lic ense or certificate to practice a business or profession suspended,
revoked, or surrendered or otherwise disciplined by any other federal, state, government agency or other
11.Have you m ai ntained a current and valid lic ens e?
12.Are you c urrent with your probation monitoring costs?
13.Have you compl i ed with each term andconditi on of your probati on?
*IF YOU ANSWERED YES, to the above quest ion numbers1 through 10 or N O to question
numbers 11 through 13, you must explain in det ailon an attached sheet of paper.
List the name, address, and work schedule (hours/days) of any other locatio n s where you practice medi cine (i. e., convalescen t /
nursing homes, etc. Provide the phone number of the Medical Director or Chief of Staff, if applicable.
Provide the titles of continuing edu cati o n cour ses you have completed for this quarter, if an y. Attach a copy of the CME certificate.
Do you p ractice any type of specialty? If yes, pl ease describ e which specialty.
List any new staff and include their ti tle and license number, if applicable.
What question(s), if any, do you have for your probation monitor regardingyour probation.
Executed on __________________________, 20_____, at _______________________________, _________
I hereby submit this Quarterly Declaration as required by the Medical Board of California and its Order of
probation thereofand declare under penalty of perjury under the laws of the State of California that I have
read the foregoing declaration and any attachmentsin their entirety and know their contents and that all
statements made are true in every respect and I understand and acknowledge that any misstatements,
misrepresentations, or omissions of material factmay be cause for further disciplinary action.
Probationer (print name) Signature
PRO-15 (Revised 3/2015)