Participant Rights and Grievance Checklist
Responsibility: Program / system · Facilitator
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Search competencies and applied modules
Ibogaine safety and risk management
Operational Tools
Ibogaine Safety and Risk Management
Educational material; not a treatment relationship.
Print a blank template and complete it offline. This website does not collect participant information.
These tools are for information quality, handoff, and accountability. Their job is to organize the case for clinical review. Numeric risk scores, dosing recommendations, and automated green light decisions would require future validation and separate regulatory review.
Participant Rights and Grievance Checklist
Provider Disclosure Sheet
Provider Disclosure Sheet
Responsibility: Program / system · Facilitator
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Credentials
licensure/scope
ibogaine experience
medical responsibility
ownership/referral relationships
conflicts
emergency partners.
Deferral and Referral Summary
Deferral and Referral Summary
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Reason for deferral
urgent concerns
what can be corrected
specialty referral
alternative treatment
reassessment conditions.
Arrival / Secondary Verification Checklist
Arrival / Secondary Verification Checklist
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Current ECG or labs when indicated
medication changes
last substance exposure
withdrawal
illness
emergency contact
travel and discharge plan.
Early Departure / Informed Refusal Record
Early Departure / Informed Refusal Record
Responsibility: Program / system · Facilitator
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Capacity
unresolved risks
alternatives offered
participant decision
transport
emergency instructions
follow-up.
Destination / Home Environment Readiness
Destination / Home Environment Readiness
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Housing
support person
mobility barriers
substance access
transportation
medications
emergency access
caregiving responsibilities.
Self-Harm and Crisis Safety Plan
Self-Harm and Crisis Safety Plan
Responsibility: Facilitator · Clinical team
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Known triggers
warning signs
participant-selected supports
access to means
emergency contacts
escalation plan.
Relapse Prevention Plan
Relapse Prevention Plan
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
High-risk situations
early warning signs
first response
naloxone/MOUD where relevant
support contacts
response after a lapse.
Onsite Observation Sheet
Onsite Observation Sheet
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
| Core field | Observation / time | Observation / time | Observation / time |
|---|---|---|---|
| Time-linked vitals and rhythm summary | |||
| intake/output | |||
| mobility | |||
| emesis | |||
| mental status | |||
| medications | |||
| unresolved concerns. |
Shift Handoff Tool
Shift Handoff Tool
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Clinical continuity
Rhythm and ECG trajectory
Vital signs and observation times
Current symptoms and changes
Medication changes
Vomiting and nausea triggers
Hydration, intake, and output where relevant
Mobility and assistance needed
Sleep
Unresolved medical concerns
Relational continuity
Preferred communication
Sensory preferences
Touch boundaries
Changes in trust, fear, or mistrust
What currently helps
What currently agitates
Participant understanding
Unresolved experiential concerns
Decisions and transfer of responsibility
Pending decisions and next actions
Responsible person and next review
Outgoing staff, incoming staff, and handoff time
Incident / Grievance Report
Incident / Grievance Report
Responsibility: Program / system · Facilitator
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Participant complaint or safety event
people involved
immediate response
escalation
retaliation protection
resolution and quality review.
Family / Trusted Support Handout
Family / Trusted Support Handout
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Expected recovery
warning signs
reduced opioid tolerance
medication plan
how to help without controlling the participant
emergency contacts.
Discharge Packet Checklist
Discharge Packet Checklist
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Medical summary
medication plan
warning signs
follow-up
records
addiction care
crisis contacts
support plan
next appointments.
Ibogaine Pre Treatment Review
Ibogaine Pre Treatment Review
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Identity
indication
treatment goals
medical and psychiatric history
substance timeline
withdrawal risk
prior ibogaine exposure
consultations
unresolved concerns
authorization decision and rationale.
Medication and Interaction Review
Medication and Interaction Review
Responsibility: Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Agent
dose
indication
last dose
QT liability
rate or conduction effect
CYP2D6 relevance
other metabolic pathway
sedative or serotonergic concern
withdrawal risk if held
responsible prescriber
plan
source.
Cardiovascular Risk Review
Cardiovascular Risk Review
Responsibility: Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
History
family history
syncope
structural disease
baseline rate and rhythm
PR
QRS
QT
QTc
correction method
morphology
ectopy
prior ECG comparison
electrolytes
QT active medications
cardiology interpretation.
Baseline Treatment Record
Baseline Treatment Record
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Time
vital signs
ECG review
relevant labs
withdrawal state
hydration
mental status
mobility
weight
recent medications
last substance use
symptoms
product verification
clinician proceed decision.
Acute Monitoring Record
Acute Monitoring Record
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Time stamped rhythm
rate
blood pressure
symptoms
consciousness
orientation
ataxia
vomiting
oxygenation when indicated
withdrawal
interventions
clinician notifications
repeat ECG and labs.
ECG Change Tracking Sheet
ECG Change Tracking Sheet
Responsibility: Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Time
heart rate
rhythm
QT
QTc
formula
PR
QRS
morphology
ectopy
pauses
symptoms
electrolytes
medications
action
reviewer.
Emergency Transfer Summary
Emergency Transfer Summary
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Product
source
amount
administration times
coadministered drugs
last substances
ECG findings and trend
labs
vitals
event chronology
interventions
response
allergies
medical history
medication list
contact
receiving facility.
Discharge Readiness Review
Discharge Readiness Review
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Cardiac reassessment
physiological stability
mental status
mobility
oral intake
medication plan
withdrawal and MOUD plan
warning symptoms
transport
supervision
referrals
follow up
understanding.
Adverse Event Report
Adverse Event Report
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Event description
onset
severity
objective findings
treatment
outcome
causality assessment
expectedness
product and dose
coexposures
reporting requirements
follow up.
Near Miss Review
Near Miss Review
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Hazard
how detected
potential consequence
failed barrier
successful barrier
contributing system factors
corrective action
owner
completion date
audit date.
Post Treatment Follow Up
Post Treatment Follow Up
Responsibility: Facilitator · Clinical team
Applies in: Medically supervised administration · Research setting
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________
Substance use
craving
withdrawal
overdose
MOUD
mood
sleep
psychosis or mania symptoms
suicidality
function
pain
medical follow up
referrals
integration needs.
Facility Readiness Audit
Facility Readiness Audit
Responsibility: Facilitator · Program / system
Applies in: Multiple settings
Guidance, scope, and evidence
Complete offline · Date: ____________________ · Completed by: ____________________