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ARIZONA STATE BOARD OF NURSING (Arizona State Board of Nursing)

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ARIZONA STATE BOARD OF NURSING
1740 W. Adams Street, Suite 2000
Phoenix AZ 85007-2607
Phone (602) 771-7800
Secure E-mail: https://www.virtru.com/secure-email/
Home Page: http://www.azbn.gov
QUESTIONNAIRE DUE BY:
PLEASE PRINT IN INK OR TYPE
THIS QUESTIONNAIRE WILL NOT BE ACCEPTED IF FILLED OUT IN PENCIL
Take time to read each question carefully and then answer it to the best of your knowledge. Do
not leave any questions unanswered. Attach additional sheets, if necessary. The questionnaire
will be returned to you if it is not filled out appropriately.
2
ARIZONA STATE BOARD OF NURSING
NAME: DATE:
ADDRESS:
PHONE: HOME ( ) WORK: ( )
RN #: ___________ LPN #: ___________ NP CERTIFIED #: ________________
R E C O V E R Y H I S T O R Y
Have you completed a drug/alcohol rehabilitation program?
Yes ____ No ____ (if yes, complete the following)
(___) Inpatient (___) Outpatient
Date of entry: ____________ Date of completion: ____________
Send documentation of proof of completion
Have you completed an aftercare program?
Yes ____ No ____ (if yes, complete the following)
Date of entry: ____________ Date of completion: ____________
Send documentation of proof of completion
Have you participated in a nurse recovery group?
Yes ____ No ____ (if yes, complete the following)
When did you join the nurse recovery group? _________________
Name of the group facilitator: ____________________________
(Have facilitator send documentation with date of entry, attendance, certification and
progress)
How often do you attend the group? ________________________
3
How has the group helped you with your recovery? (be specific)
Have you participated in a twelve-step program (AA or NA)?
Yes ____ No ____ (if yes, complete the following)
When did you begin your twelve-step program? ________________
How often do you attend meetings? Weekly ________ More than once a week ________
4
Monthly ________ Other ______________
Do you have a home group?
Yes ____ No ____ (if yes, complete the following)
Name of Home Group: _______________________________________
Do you have a sponsor? Yes ____ No ____ (If yes, complete the following)
How long have you had this sponsor? _______________________
How often do you meet and/or have contact with your sponsor?
Have your current sponsor write a letter to the Board addressing the length of time he/she
has been your sponsor, addressing your twelve-step activities and their general impression
of your recovery status. The Board respects the twelve-step anonymity and the sponsor
letter then need only be signed with their first name. If your sponsor is willing to release
their phone number, ask them to submit it.
How many sponsors have you had within the last three years?
_________________________________________________________________________
Have you completed the twelve steps? Yes ____ No ____
(If "No" what step are you on?) _________________________________________
Have you read the Big Book? Yes ____ No ____
If you have not completed reading the Big Book, what chapter are you on?
______________________________________________________________
How has this program helped you with your recovery? (be specific)
5
If you have not participated in a twelve-step program, have you participated in an
alternative program such as Rational Recovery or any other program?
Yes ____ No ____ (if yes, complete the following)
Briefly describe the function of the program and how it has benefited you in recovery.
Since you have had your license, have you had any drug screens?
Yes ____ No ____ (if yes, submit copies of results of drug testing)
6
Since you have had your license, have you been evaluated by an addictionist? Yes ____
No ____ (if yes, send documentation) Evaluations by an addictionist must include a
complete history and physical, laboratory test and an interview evaluation.
Since you have had your license, have you been evaluated
by a relapse prevention counselor? Yes ____ No ____ ( if yes, send documentation of
evaluation)
If yes, what are your relapse warning signs? (be specific)
Since you have had your license, have you had any counseling for your substance abuse
problem? Yes ____ No ____
(if yes, send documentation)
Describe your recovery program (include your support system)
7
M E D I C A L H I S T O R Y
Describe any current acute or chronic medical problems (include hospitalization, surgery,
fractures, accidents, dental work, emergencies--give dates; be specific)
Describe any acute or chronic medical problems occurring during the past five years
(include hospitalization, surgery, fractures, accidents, dental work, emergencies--give
dates; be specific)
List all current prescription, self-prescribed and over-the- counter medications. F or
prescription medication, list name of the prescribing provider, name of medication, reason
for medication, date of prescription
8
Prescription cont:
Do you have one primary care provider? Yes ____ N o ____ ( if yes, give name and
address of provider
Does the above provider know of your chemical dependency?
Yes ____ No ____
If you are currently on a ny narcotics, non-narcotic analgesics, hypnotics, or any mood-
altering medications, have the provider who prescribed write a letter to the Board stating
reason for prescription, length and expected use, and addressing their knowledge of your
chemical dependence
How would you describe your current health status?
9
Health status cont.
C U R R E N T S U B S T A N C E A B U S E H I S T O R Y
(legal and/or illegal)
Current alcohol and/or drug use (check all that are applicable)
STIMULANTS INHALANTS CANNABIS ANABOLIC
STEROIDS
___Alcohol ___Cocaine List use ___THC List use
___Amphetamines ________ ___Marijuana _____________
___Nicotine ________ ___Hashish _____________
___Caffeine ________ _____________
NARCOTIC ANALGESICS:
___codeine based ___methadone ___fentanyl (sublimaze)
___darvon ___morphine ___talwin
___demerol ___opium ___tylox
___dilaudid ___percocet ___vicodan
___heroin ___percodan ___other (specify)
NON-NARCOTIC ANALGESICS:
___ nubain ___stadol ___other (specify)
HYPNOTICS:
___chloral hydrate (noctec) ___halcion
___soma ___phenobarbital ___nembutal
___other (specify)
ANTI-ANXIETY:
___ativan ___tranxene ___xanax
___librium ___valium ___other (specify)
10
HALLUCINOGENS:
___LSD ___PCP ___STP MOA
___Mescaline ___other (specify)
What was your drug(s) of choice (including alcohol)?
P A S T S U B S T A N C E A B U S E H I S T O R Y
(legal and/or illegal)
Past alcohol and/or drug use (check all that are applicable)
STIMULANTS INHALANTS CANNABIS ANABOLIC
STEROIDS
___Alcohol ___Cocaine List use ___THC List use
___Amphetamines ________ ___Marijuana _____________
___Nicotine ________ ___Hashish _____________
___Caffeine _____________
NARCOTIC ANALGESICS:
___codeine based ___methadone ___fentanyl (sublimaze)
___darvon ___morphine ___talwin
___demerol ___opium ___tylox
___dilaudid ___percocet ___vicodan
___heroin ___percodan ___other (specify)
NON-NARCOTIC ANALGESICS:
___ nubain ___stadol ___other (specify)
HYPNOTICS:
___chloral hydrate (noctec) ___halcion
___soma ___phenobarbital ___nembutal
___other (specify)
11
ANTI-ANXIETY:
___ativan ___tranxene ___xanax
___librium ___valium ___other (specify)
HALLUCINOGENS:
___LSD ___PCP ___STP MOA
___Mescaline ___other (specify)
What was your drug(s) of choice (including alcohol)?
How were the drugs listed on pages 9-10 obtained? (be specific)
prescription abuse ___Yes ___No
diversion ___Yes ___No
street purchase ___Yes ___No
writing your own Rx ___Yes ___No
presenting illegal Rx ___Yes ___No
other (explain)
12
How long have you been clean of prescription or illegal drugs?
_____________days _____________months _____________years
How long have you been sober?
_____________days _____________months _____________years
Do you smoke cigarettes and/or have any other tobacco usage?
___Yes ___No (if yes, describe use)
OTHER ADDICTIONS (if in current or past counseling for any, send
documentation)
___ food ___ shopping ___ shoplifting
___ relationships ___ gambling ___ sex
___ other ___ none of the above
E M P L O Y M E N T H I S T O R Y:
Current employer: _________________________________________________________
Employer's Address: _______________________________________________________
Phone No.: _______________________________________________________________
Supervisor: _______________________________________________________________
Is supervisor aware of your substance abuse problem?
___Yes ___No
13
If you are currently employed, have your supervisor write a letter on t heir letterhead
stationery to the Board addressing the length of time of your employment, attendance
record, and their general evaluation of your performance. (If you have been employed by
more than one agency within the last 18 months, have each supervisor write to the Board
as instructed above.
List the places you have been employed for the past 3-5 years including the address and
telephone.
L E G A L H I S T O R Y (current and past)
In the past, or currently, have you been on civil or criminal probation? ___Yes ___No (if
yes, briefly explain reason for probation). Also have your probation office write a letter to
the Board stating the reason for your probation, length of time and your compliance with
your probation requirements.
14
Have you ever been arrested while driving under the influence
of drugs and/or alcohol? ___Yes ___No (if yes, explain when, where and disposition of
arrest)
15
Have you engaged in illegal activities in order to obtain drugs? (if yes, explain)
Have you ever been arrested for possession of illegal drugs?
(if yes, explain when, where and disposition of arrest)
16
L I C E N S E I N F O R M A T I O N:
Have you ever had any disciplinary action on your license in Arizona or any other state?
___Yes ___No
If yes, briefly explain why for each state in which the discipline occurred and the current
disposition of your license in that state.
If there is a current complaint with the Arizona State Board of Nursing against your
license, give a brief summary and describe your version of the events of the complaint.
17
What do you like best about being a nurse?
What do you like least about being a nurse?
18
AFFIDAVIT
STATE OF _________________________
County of ________________________
The undersigned being duly sworn declares that he/she is the person referred to in the foregoing
application; that the statements are true in every respect; that he/she has not suppressed any
information that would affect this application: that he/she will conform to the ethical standards
of conduct in the profession of nursing; and that he/she has read and understands this affidavit.
________________________________
SIGNATURE
SUBSCRIBED AND SWORN to before me this __________________ day of
____________________, .
Commission Expires:
__________________ ________________________________
Date Notary Public
Notary Seal
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ARIZONA STATE BOARD OF NURSING (Arizona State Board of Nursing)

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Completed 12 August 2020

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