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Specialist Doctor / Therapist Obstetrician / Gynecologist General Practioner Nurse / Clinical Officer
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Are you now or have you ever been involved in any litigation, lawsuits, claims, or arbitration, or are you now involved in any threatened litigation or claim related to your professional activities?

Have judgments or settlements been made against you in professional liability cases or are you involved in any pending litigation or denied liability insurance at standard rates?

Have you ever been denied liability insurance?

Has your membership or renewal thereof in any medical organimtion ever been revoked, suspended, diminished, or denied?

Have your privileges in any hospital ever been suspended, diminished, revoked, denied or not renewed?

Have you ever been charged with any crime other than minor traffic violations?

Has your license in any jurisdiction ever been limited, suspended, or revoked?

Have you ever been subject to any disciplinary proceeding or action by any employer, hospital, or other entity or institution with respect to your professional activities or behavior?

Have you ever received treatment, voluntarily or involuntarily for alcoholism or drug abuse, mental illness or psychiatric problems?

Do you have any current or past health problems or conditions that would impact or limit your ability to practice medicine in a developing country?