Ill. Admin. Code tit. 68 § 1130 app. A
NOTICE OF ORDER REQUIRING CHAPERONE
The Illinois Department of Financial and Professional Regulation has ordered ***INSERT PRACTITIONER'S NAME*** to have a chaperone who is a licensed health care worker present during all patient encounters pending the outcome of criminal charges against him/her. In compliance with this Order, please sign below to acknowledge that you have received a copy of this notice.
The health care worker is presumed innocent until proven guilty of the charges.
Patient:
_____________________________________________________________
Print Name
_________________________________________________________
SignatureDate
Chaperone:
_____________________________________________________________
Print Name
_________________________________________________________
SignatureDate
Ill. Admin. Code tit. 68, 1130 app A