12. Character and Fitness Questions (Check either YES or NO) Please answer questions “a”
through “q” on pages 4 and 5.
RCP
CHARACTER & FITNESS
4/2017
Print
Your
Name: __________________________________________________________________________ Date:______________
Page
4 of 6
YES NO (Since your last renewal)
Has a state licensing or disciplinary board (including Maryland), a comparable body in the armed services
or the Veterans Administration, denied your application for licensure, reinstatement, or renewal?
Has a state licensing or disciplinary board (including Maryland), a comparable body in the armed
services or the Veterans Administration, taken action against your license? Such actions include, but are
not limited to, limitations of practice, required education admonishment or reprimand, suspension,
probation or revocation.
Has a hospital, related health care institution, HMO, or alternative health care system investigated you
or brought charges against you?
Has a hospital, related health care institution, HMO, or alternative health care system denied your
appli-cation; failed to renew your privileges, including your privileges as a resident; or limited, restricted,
suspended, or revoked your privileges in any way?
Have you pleaded guilty or nolo contendere to any criminal charge, been convicted of a crime,
or received probation before judgment because of a criminal charge?
Have you committed an offense involving alcohol or controlled dangerous substances to which you pled
guilty or nolo contendere, or for which you were convicted or received probation before judgment?
Such offenses include, but are not limited to, driving while under the influence of alcohol or controlled
dangerous substances.
Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol
abuse, or a physical, mental, emotional, or nervous disorder or condition) that in any way affects your
ability to practice your profession in a safe, competent, ethical, and professional manner?
Has any licensing or disciplinary board in any jurisdiction (including Maryland), a comparable body in
the armed services or the Veterans Administration, filed any complaints or charges against you or
investigated you for any reason?
Have you withdrawn your application for a medical license or other health professional license?
Are there any charges pending against you in any court of law, are you currently under arrest, released
pending trial with or without bond, or is there an outstanding warrant for your arrest?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Continue to Page 5 for questions “l” through “q”
Have any malpractice claims or other claims for money damages been filed against you? Include past
claims as well as any claim that is now pending, has been dismissed, has been settled, or which has
resulted in a damages award against you or your medical practice.
k.
If you answered “YES” to any question, on a separate sheet of paper, please provide a signed and dated detailed explanation
and attach appropriate supporting documents. Failure to provide documentation and a signed and dated explanation will delay
the processing of your application.