Welcome to IDHS FOID Mental Health Reporting System

Qualified Examiner Information Page

Please Note: A Qualified Examiner who uses this page chooses not to register with the DHS FOID Mental Health Reporting System and will be required to enter their demographic information each time they report information. Information reported as a guest cannot be changed on a later date by the reporter using the FOID web site. The Qualified Examiner will be required to E-Mail IDHS at DHS.FOID@Illinois.gov to explain what change is needed.

Please Enter Qualified Examiner Information below:

* Qualified Examiner First Name:

Qualified Examiner Middle Name:

* Qualified Examiner Last Name: (enter exactly as spelled on Qualified Examiner License) :

* Last 4 Digits of SSN:

* Qualified Examiner License Number (enter 8 or 9 numeric characters exactly as it appears on Qualified Examiner License, no dashes, no periods):

* Qualified Examiner Work Phone:
() -

Ext:

* Qualified Examiner Work E-Mail:

* Confirm Work E-Mail:

* Qualified Examiner Practice Name (where person presented):

* Qualified Examiner Work Address:

Qualified Examiner Work Address2:

* Qualified Examiner Work City:

* State:

*Zip:

Ext:

* Qualified Examiner Referral Method:

* Qualified Examiner Type:

Please Enter Event Information below:

*First Name:

Middle Name:

*Last Name:

Suffix:

Medical Record Number :

Contact Serial Number:

Leave Social Security Number field blank if unknown. Do not submit fake social security numbers.

Social Security Number:

*Date of Birth:(mm/dd/yyyy)

Homeless You will not be able to enter address below if this Homeless Indicator is checked.

*Address:

Address 2:

*City:

*State:

*Zip:

Ext:

*Gender:

*Race:

Eye Color:

Hair Color:

Height(feet) & Height(inches):

Weight(pounds):

* Event Type(Choose all that apply):
Clear and Present Danger Developmentally Disabled Intellectually Disabled

*Clear and Present Danger Event Date: (mm/dd/yyyy)

*Qualified Examiner Note (Please briefly describe why you believe this person is a clear and present danger):

500 characters left

*Developmentally Disabled Event Date: (mm/dd/yyyy)

*Intellectually Disabled Event Date: (mm/dd/yyyy)

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