Fillable Arizona State Board of Nursing (Arizona State Board of Nursing)

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Arizona State Board of Nursing (Arizona State Board of Nursing)

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Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 West Adams Street, Suite 2000
Phoenix, AZ 85007-2607
Phone: (602) 771-7800
Homepage: http://www.azbn.gov
INVESTIGATIVE QUESTIONNAIRE
ATTENTION: ,
TO BE COMPLETED BY BOARD STAFF
Nature of concern or complaint submitted against you:
(It is a violation of R4-19-403.25(a.) to fail to furnish in writing a full and complete explanation covering
the matter reported pursuant to A.R.S. § 32-1664).
PLEASE COMPLETE AND RETURN THIS FORM BY:
I. RESPONDENT INFORMATION:
Name: License No.:
Primary State of Residence (Where you vote, pay
federal taxes, current driver’s license):
Address:
Telephone Numbers:
:emoH
Work:
E-Mail:
Cell Phone:
Have you ever been licensed in any other state?
Yes No
If yes, list all states and current status of license:
Where did you receive your nursing education?
Case No.
2
I. RESPONDENT INFORMATION: (continued)
1. Indicate all degrees you hold and list the year of graduation and year of initial licensure, if applicable.
Degree(s)
Year of
Graduation
Year of
Graduation
Unknown
Year of Initial
Licensure
Year of Initial
Licensure Unknown
Practical/Vocational
Associate Degree - LPN
Associate Degree - RN
Diploma – RN
Baccalaureate, Nursing
Masters, Nursing
Doctorate, Nursing
Bachelors, non- Nursing
Advanced Degree, non-Nursing
Other nursing
Degree Held by Nurse (Unknown)
2. Current licensure/certificate status? Check all that apply.
LPN/VN RN APRN Licensure status unknown
Nurse Practitioner
Clinical Nurse Specialist
Nurse Anesthetist
Nurse Midwife
APRN Category unknown
3. Is English your primary language?
Yes No
II. EMPLOYMENT INFORMATION
A. Current Employer(s):
1. Employer:
Address:
Job title:
Supervisor:
Date of Hire:
Phone No.:
2. Employer:
Address:
Job title:
Supervisor:
Date of Hire:
Phone No.:
Case No.
3
II. EMPLOYMENT INFORMATION (continued)
B. Previous Employer(s):
List all previous employers (full-time, part-time and registry employers) for the past five years. If a traveling assignment,
list both facility and agency. DO NOT ATTACH RESUME
1. Employer:
Address:
Job title:
Supervisor:
Phone No.:
Start Date: End Date:
Were you terminated or did you resign in lieu of termination from previous employment? Yes No
:gnivael rof nosaer ruoy eton ro nialpxe esaelp ,sey fI
2. Employer:
Address:
Job title:
Supervisor:
Phone No.:
Start Date: End Date:
Were you terminated or did you resign in lieu of termination from previous employment? Yes No
:gnivael rof nosaer ruoy eton ro nialpxe esaelp ,sey fI
3. Employer:
Address:
Job title:
Supervisor:
Phone No.:
Start Date: End Date:
Were you terminated or did you resign in lieu of termination from previous employment? Yes No
:gnivael rof nosaer ruoy eton ro nialpxe esaelp ,sey fI
Were you terminated or did you resign in lieu of termination from any previous employment? Yes No
If yes, please provide an explanation:
Case No.
4
III. DESCRIPTION OF EVENT
Provide information regarding the incident leading to the complaint filed against your (license/certificate) at the Arizona
State Board of Nursing, i.e., describe events and include any information that would be helpful for the Board in
understanding the allegations.
(Attach additional sheets if needed).
Case No.
5
IV. WITNESSES
List the witnesses you would like contacted regarding the incident(s). A witness is anyone who saw the alleged
incident occur or otherwise had first-hand knowledge about the incident.
pihsnoitaleR kroW .oN enohP sserddA emaN
V. ANALYSIS OF EVENT
Was a patient or patients involved in the reported event/events? Yes No
If the answer is yes please complete the remainder of this section to the best of your ability/knowledge. Even if more than one
patient was involved please complete the remainder of this section for the patient that is the focus of the complaint.
If a patient or patients were not involved, please skip to section VI (page 14)
4. Length of time you worked in the patient care location (unit/department/area) where the reported event
occurred. Select one of the answers below.
Less than one month One - Two years More than five years
One month - Eleven months Three - Five years Unknown
5. What type of shift were working at the time of the reported event?
Select one of the answers below or add your own.
8 hour On call
10 hour Unknown
12 hour Other please specify
6. Were you working in a temporary capacity (e.g., traveler, float pool, float to another unit, covering a
patient for another nurse)?
Yes No
7. How many direct care patients were assigned to you at the time of the reported event?
Number of patients
Unknown
8. Do you have a history of discipline by current or previous employer(s) for practice issues?
Select one of the answers below.
Yes No Unknown
9. Employment Outcome? Check all that apply and/or add your own variant.
Still employed by same Employer My Employer terminated/dismissed me
I resigned as a result Unknown
I resigned in lieu of termination Other - please specify
Case No.
6
10. Do you have any previous discipline history by a board of nursing? Select one of the answers below.
Yes No Unknown
11. Do you have any previous criminal convictions? Please pick one of the answers below.
Yes No Unknown
12. Patient Age:
Under 1 year 26 - 35 years
1 - 3 years 36 - 49 years
4 - 6 years 50 - 64 years
7 - 11 years 65 and above
12 - 18 years Unknown
19 - 25 years
13. Patient gender
Male Female Unknown
14. Indicate the patient's diagnosis. Check no more than TWO diagnoses, those that contributed to the reported
situation.
BLOOD AND BLOOD-FORMING ORGANS DISEASE/DISORDER (e.g. Anemias; Sickle Cell;
Thrombocytopenia; Lymphadenitis; etc.)
CANCER (e.g. Leukemia; Lymphoma; Breast Cancer; Uterine Cancer; Melanoma; Carcinoma; Sarcoma; etc.)
DIGESTIVE SYSTEM DISEASE/DISORDER (e.g. Pancreatitis; Liver Failure; Hepatitis; Appendicitis; C-difficile;
Intestinal Obstruction; G I Hemorrhage; Diverticulitis; Crohn’s Disease/Irritable Bowel Syndrome; Nausea/Vomiting;
etc.)
ENDOCRINE, METABOLIC, AND IMMUNE SYSTEMS DISEASE/DISORDER (e.g. Diabetes; HIV/AIDS; Fluid
and Electrolyte Disorders; Thyroid Disorder; Addison’s Disease; Cushing’s Disease; Lupus; Cystic Fibrosis; etc.)
GENITOURINARY SYSTEM DISEASE/DISORDER (e.g. Acute/Chronic Renal Failure; Kidney Stones; Enlarged
Prostate; Urinary Tract Infection; Endometriosis; STDs; etc.)
HEART & CIRCULATORY SYSTEM DISEASE/DISORDER (e.g. Coronary Artery Disease; Heart Attack;
Congestive Heart Failure; Hypertension; Aneurysms; Cardiac Dysrhythmias; Syncope; Stroke (CVA); Transient
Ischemic Attack; etc.)
INJURY/TRAUMA (e.g. Accidents; Falls; Motor Vehicle Accidents; Rape; Assault; gunshot; Electrocution;
Poisoning; etc.)
MENTAL HEALTH CONDITIONS (e.g. Depression; Anxiety; Psychoses; Bi-Polar; Substance
Use/Abuse/Dependency; Suicide/Attempt; Personality Disorder; Attention Deficit/Hyperactivity Disorder; Mental
Retardation; etc.)
MUSCULOSKELETAL SYSTEM DISEASE/DISORDER (e.g. Fractures; Arthritis; Back problems; Osteoporosis;
etc.)
NERVOUS SYSTEM OR SENSE ORGAN DISEASE AND DISORDER (e.g. Alzheimer’s Disease and other
Dementias; Parkinson’s; Multiple Sclerosis; Seizures; Headache; Meningitis; Encephalitis; Glaucoma; etc.)
PREGNANCY, CHILDBIRTH, and RELATED CONDITIONS/COMPLICATIONS (e.g. Normal/Abnormal
Pregnancy and/or Delivery; Fetal Distress; etc.)
RESPIRATORY SYSTEM DISEASE/DISORDER (e.g. Pneumonia; Chronic Obstructive Pulmonary Disease;
Influenza; Upper/Lower Respiratory Infection; Asthma; Bronchitis; Pulmonary Embolism; Tuberculosis; etc.)
SKIN DISEASE/DISORDER (e.g. Wounds; Burns; Cellulitis; Dermatitis; etc.)
SYSTEMIC INFECTIONS/INFECTIOUS DISEASES (Bacterial, Viral, and Parasitic) (e.g. Septicemia; Lyme
Disease; MRSA; VRE; E-coli; etc.)
Case No.
7
Unknown (If you select this option, do not select any other choices)
Other – please specify
15. Indicate whether the patient exhibited any of the following at the time of the reported event. Please check
all that apply.
Agitation/Combativeness Incontinence
Altered level of consciousness Insomnia
Cognitive impairment Pain
Communication/Language difficulty Sensory deficits (hearing, vision, touch)
Depression/Anxiety None of the above
Inadequate coping /stress management Unknown
16. Type of facility or environment Please pick one of the answers below or add your own.
Ambulatory Care Home Care Physician/Provider Office or Clinic
Assisted Living Hospital Unknown
Behavioral Health Long Term Care Other – please specify
Critical Access Hospital Office-based surgery
17.
Patient Harm Please pick one of the answers below.
No harm - An error occurred but with no harm to the patient
Harm - An error occurred which caused a minor negative change in the patient's condition.
Significant harm - Significant harm involves serious physical or psychological injury. Serious injury specifically
includes loss of function or limb.
Patient death - An error occurred that may have contributed to or resulted in patient death.
18. Communication Factors Please check all that apply and/or add your own variant.
Communication systems equipment failure Patient identification failure
Interdepartmental communication
breakdown/conflict
Computer system failure
Shift change (patient hand-offs) Lack of or inadequate orientation / training
Patient transfer (hand-offs) Lack of ongoing education / training
No adequate channels for resolving disagreements No communication factors involved
Preprinted orders inappropriately used (other than
medications)
Unknown
Medical record not accessible Other – please specify
Patient name similar/same
Case No.
8
19. Leadership/Management Factors Please check all that apply and/or add your own variant.
Poor supervision/support by others Inadequate patient classification (acuity)
system to support appropriate staff assignments
Unclear scope and limits of authority/responsibility No leadership/management factors involved
Inadequate/outdated policies/procedures Unknown
Assignment or placement of inexperienced personnel Other – please specify
Nurse shortage, sustained, at institution level
20. Backup and Support Factors Check all that apply and/or add your own variant.
Ineffective system for provider coverage
Lack of adequate response by lab/x-ray/pharmacy or
other department
Lack of adequate provider response No backup and support factors involved
Lack of nursing expertise system for support Unknown
Forced choice in critical circumstances Other – please specify
21. Environmental Factors Check all that apply and/or add your own variant.
Poor lighting Similar/misleading labels (other than medications)
Increased noise level Code situation
Frequent interruptions/distractions No environmental factors involved
Lack of adequate supplies/equipment Unknown
Equipment failure Other – please specify
Physical hazards
Multiple emergency situations
22. Other Health team members who contributed to the report event Check all that apply and/or add your own
variant.
Supervisory nurse/personnel Other support staff
Physician (may be attending, resident or other) Patient
Other prescribing provider Patient's Family/friends
Pharmacist Unlicensed Assistive Personnel (nurse aide,
certified nursing assistant, CNA or other titles of
non-nurses who assist in performing nursing tasks)
Additional Staff nurse No health team members contributed
Floating/temporary staff
Unknown (If you select this option, do not select
any other choices.)
Other Health professional (e.g., PT, OT, RR) Other-please specify
Health profession student
Medication assistant
23. Did staffing issues contribute to the reported event? Check all that apply
Lack of supervisory/management support Lack of other health care team support
Lack of experienced nurses None (If you select this option, do not select any
other choices)
Lack of nursing support staff Unknown (If you select this option, do not select
any other choices)
Lack of clerical support Other – please specify
Case No.
9
24. Health care team Check all that apply
Intradepartmental conflict/non-supportive
environment
Illegible handwriting
Breakdown of health care team communication Lack of patient education
Lack of multidisciplinary care planning Lack of family/caregiver education
Intimidating/threatening behavior None (If you select this option, do not select any
other choices.)
Lack of patient involvement in plan of care Unknown (If you select this option, do not select
any other choices.)
Care impeded by policies or unwritten norms that
restrict communication
Other – please specify
Majority of staff had not worked together
previously
25. Did the reported incident involve intentional misconduct or criminal behavior?
Check all that apply and/or add your own variant.
No Yes: Patient abuse (verbal, physical, emotional or
sexual)
Yes: Changed or falsified charting Yes: Criminal conviction
Yes. Deliberately covering up error Yes: Other - please specify
Yes: Theft (including drug diversion) Unknown (if you select this option, do not select
any Choices.)
Yes: Fraud (including misrepresentation)
26. Did the reported event involve a medication error?
Yes No
27. The type of medication error identifies the form or mode of the error, or how the error was manifested.
Select the type of medication error. Check all that apply and /or add your own variant.
Abbreviations Wrong dosage
Drug prepared incorrectly Wrong drug
Extra dose Wrong patient
Mislabeling Wrong route
Omission Wrong time
Prescribing Wrong reason
Unauthorized drug Unknown
Wrong administration technique Other – please specify
28. If the wrong drug was involved in the reported event, please list the name of the drug
Drug ordered
Unknown
Drug actually given Unknown
29. Was a documentation error involved? Yes No
Pre-charting / untimely charting Charting on wrong patient record
Incomplete or lack of charting Other – please specify
Charting incorrect information
30. Did the documentation error lead to the reported event?
Yes No
Case No.
10
OPTIONAL QUESTIONS
1. Were the patient's family and/or friends present at the time of the reported event? Select only one
Yes No Unknown
2. Type of Patient Event Related to Practice Breakdown Check all that apply and/or add your own variant.
Abuse Patient Fell
Allergic/Anaphylaxis/Transfusion Reaction Suicide
Equipment Failure Treatment Error/ Omission
Healthcare Associated Infection Unknown
Homicide Other-Please specify
Medication error
3. Type of community
Select only one
Rural (lowly populated, farm, ranch land communities 10,000 or less)
Suburban (towns, communities of 10,000 to 50,000)
Urban (any city over 50,000)
Unknown
4. Facility size
Select only one
5 or fewer beds 100-199 beds 500 or more beds
6-24 beds 200-299 beds Not applicable
25-49 beds 300-399 beds Unknown
50-99 beds 400-499 beds
5. Medical record system Select only one
Electronic documentation Paper documentation
Electronic medication administration system Combination paper/electronic record
Electronic physician orders Unknown
6. Did the nurse report completion of any continued competence activities or professional
development activities in the last five years?
Select only one
Yes No Unknown
7. Work start and end times (based on a 24 hour clock) when the reported event occurred
Start time am/pm End time am/pm
Time of incident am/pm Unknown
8. Length of time the nurse had worked for the organization where the practice breakdown occurred
Select only one
Less than one month One - Two years More than five years
One month - Eleven months Three - Five years Unknown
Case No.
11
9. Length of time the nurse had been in the specific nursing role at the time of the practice
breakdown Select one of the answers below.
Less than one month Three - Five years
One month - Eleven months More than five years
One - Two years Unknown
10. Days worked in a row at the time of the practice breakdown (include all positions/employment)
Select one of the answers below.
First day back after time off Six or more days
Two - Three days Unknown
Four - Five days
11. Assignment of the nurse at time of the practice breakdown Select one of the answers below.
Direct patient care
Non-patient care
Unknown
12. How many staff members was the nurse responsible for supervising at the time of the practice
breakdown?
Number of Staff Unknown
13. How many patients was the nurse responsible for overall (counting direct care patients and the
patients of the staff the nurse was supervising at the time of the practice breakdown)?
Number of Patients Unknown
14. Nurse's reported perception of factors that contributed to the practice breakdown.
Check all that apply and/or add your own variant.
Nurse's language barriers
Nurse's cognitive impairment
Nurse's high work volume/stress
Nurse's fatigue/lack of sleep
Nurse's drug/alcohol impairment/substance abuse
Nurse's functional ability deficit
Nurse's inexperience (with clinical event, procedure, treatment or patient condition)
No rest breaks/meal breaks
Nurse's lack of orientation/training
Nurse's overwhelming assignment(s)
Nurse's lack of team support
Nurse's mental health issues
Nurse's conflict with team members
Nurse's personal pain management
Lack of adequate staff
None (If you select this option, do not select any other choices)
Unknown (If you select this option, do not select any other choices)
Other - please specify
Case No.
12
15. Supervisor or employer's perception of factors that contributed to the practice breakdown.
Check all that apply and/or add your own variant.
Nurse's language barriers
Nurse's cognitive impairment
Nurse's high work volume/stress
Nurse's fatigue/lack of sleep
Nurse's drug / alcohol impairment/substance abuse
Nurse's functional ability deficit
Nurse's inexperience (with clinical event, procedure, treatment or patient condition)
No rest breaks / meal breaks
Nurse's lack of orientation/training
Nurse's overwhelming assignment(s)
Nurse's lack of team support
Nurse's mental health issues
Nurse's conflict with team members
Nurse's personal pain management
Lack of adequate staff
None (If you select this option, do not select any other choices)
Unknown (If you select this option, do not select any other choices)
Other - please specify________________
16. Terminated or resigned in lieu of termination from previous employment
Select one of the answers below.
Yes No Unknown
17. Select which factors contributed to the medication error. Check all that apply and/or add your own
variant.
Blanket orders Leading/Missing zero
Brand/generic drugs look alike Measuring device inaccurate/inappropriate
Brand names look alike Medication available as floor stock
Brand names sound alike Monitoring inadequate/inappropriate
Calculation error Non-formulary drug
Communication Non-metric units used
Computer entry Packaging/container design
Computerized prescriber order entry Patient identification failure
Computer software Performance (human) deficit
Contra-indicated in disease Performance deficit
Contra-indicated in pregnancy/breastfeeding Prefix/Suffix misinterpreted
Contra-indicated, drug/drug Preprinted medication order form
Contra-indicated, drug allergy Procedure/Protocol not followed
Decimal point Pump: failure/malfunction
Dilutant wrong Pump: improper use
Dispensing device involved Reconciliation – Admission
Documentation inaccurate/lacking Reconciliation – Discharge
Case No.
13
Dosage form confusion Reconciliation material confusing/inaccurate
Drug devices Repackaging by other facility
Drug distribution system Repackaging by your facility
Drug shortage Similar packaging/labeling
Equipment design confusing/inadequate Similar products
Equipment (not pumps) failure/malfunction Storage proximity
Fax/Scanner involved System safeguard(s) inadequate
Generic names look alike Trailing/terminal zero
Generic names sound alike Transcription inaccurate/omitted
Handwriting illegible/unclear Verbal order
Incorrect medication activation Workflow disruption
Information management system Written order
Knowledge deficit Unknown
Label - Manufacturer design Other (Specify)
Label - Your facility's design
Case No.
14
VI. ARRESTS/CITATIONS/CHARGES
Have you ever been arrested, cited or charged? Yes No
If yes, please complete pages 15 and 16 of this questionnaire.
VII. Attach any other documentation related to the complaint you would like reviewed.
If no response is received, the Investigative Report will proceed and your case will be presented at a future
Board of Nursing meeting for discussion and recommendations. Be advised that failing to cooperate with the
Board by not furnishing in writing a full and complete explanation covering the matter reported pursuant to
A.R.S. § 32-1664 is considered unprofessional conduct and is grounds for disciplinary action.
I verify that the above information provided by me is true, complete and correct to the best of my knowledge
and belief.
______________________________________ ______________________________
etaD erutangiS
Thank you for your assistance. Please return to:
Attention: ,
Arizona State Board of Nursing
1740 W. Adams Street, Suite 2000
Phoenix, Arizona 85007-2607
Telephone No.: (602) 771-
E-mail:
Case No.
15
ARREST/CHARGE/CITATION QUESTIONNAIRE
RE: (Case No. )
Instrucons:
• A completed re MUST BE submed for EACH rrest, chrge, or c you ve ever receved, rerdless of
 or outcome (excludg l . DUIs, Reckless , or        c c).
mcts must y were ultelymed.
• ey the qureed order to pspt.
•  p  or type. R   efully   every  “See ed”  ot  ptle
wer.
• Complete and submit ALL pages of the quesonnaire, sign and date the last page, and ch the required police and
court records as well as your detailed wrien statement.  of your  w be ded  
res  be se  t     submed     for every 
chge, or cto, regdless of ge or outcome. Flure to p the reqed docu  be cdered  to
th they sute 
he Nue Act.
1. Demographic Informaon:
Full Nme: __________________________________________________________________________________
Frst ddle Lst
All Other/Former Nmes): ________________________________
___________________________________________________________________________________________
ecurty Number: ________________________rth: __________________________________
Address: ____________________________________________________________________________________
Street Cty Stte Zp
e Number: __________________________ Cell/Moble Number: _____________________________
2. Arreon Infor
lo restyou.
w e or sh____________________________________________
g: _____________________________________________________________________
Street Cty Stte Zp
d/ced: ______________________
eyod or cted? _____________________________________________
Werrerger:
emer y
e requested from thsetcy m submg wth thsrble, ALL
d polce recsted below:
• eport, co, ctetf  AND
• t dertmereport. Therres why the r mde cot
uded durc AND
• All supplemeos to the repug results of tes,o, etc.
m subquetd  (or tyemeegumst
gh
Case No.
16
When subming a en explan, be suree as spee and address the “, what, when, where,
why and w”e circumstances regarding the incident. This ll thened in
rds. Failure tdetailed statement regarding each incident ise Nurse Pce Act.
3. Court Informa�on:
lregarding theerer care yur charges
icable.
urt: ________________________________________________________________________
_____________________________________________________________________
Street ity State Zip
ense(s) were yicted?___________________________________________________________
ic____________________
:
misdemeanr y undesignated
lead:
guilty cendere ntest
What was the sentence? (Include all ne, re, prare,
unityetc)
___________________________________________________________________________________________
___________________________________________________________________________________________
hindesignated at was the datelnn
requirements, including pauand ru (Yu must includmple
urt requirement inl)? _____________________
Has there been any change in the desigur since the riginal sentencing (Exa
misdemeadismissed, expunged,red)?
N Yes
nge? _____________________________________________________________
en ae?
N Yes
en icipateharge date? __________________________
rp__________________________
phnumber: _________________________
diyr prr was a warr issued?
N Yes
Ibe the circumse __________________________________________
_____________________________________________________________________________________
Was yr sentence med as a reyr pra
N Yes
Explain: ______________________________________________________________________________
e requem thisand am subming with this queicable, ALL requir
:
• eint, indictment. This will shw the erith;
AND
• Pre-sentence screening, repral, pre-sentence r AND
Case No.
17
• Plea agreement/s if applicable AND
• Sentencing, pder/judgment. This will show the requirements imposed by the court AND
• ease, court discharge.
4. Document Requirements
Check he boxes below to ensure you have provided all documn required to be submied with this
re.
A Detailed Wren (or Typed) Statement.
ALL Police, S, or Law Enforcement Records.
ALL Court Documents.
4a) If no formal court charges resulted from the arrest or cion, you mull include the police report. However, in place
of the court records listed above, please provide:
• Documentorom the police department or court stang that no charges led or that
n was declined.
4b)or charge occurred several years ago and police or court records have been purged or are no longer
available, a document on lhead from the police department and court stang that the files on your case no longer
exist, will be required and acceptable if it includes the following:
• Your name, date of birth, social security number (used by the agency to conduct the search).
• The type of charge (what the arrest was for) and the date and year the arrest transpired.
• Name/phone number of the police department or court contact person.
I verify that the above informaon provided by me and answered within this quesonnaire is true, complete and correct,
and I have disclosed each of my arrests,ons and charges, for felonies and misdemeanors, including incidents that did
not ulmately result inns.
__________________________________________________________ _________________________
Signature Date
RE: /
Case No.
18
Complaint or Self-Report Process

1. What happens with the complaint?


 

 

 h

 
 h
2. Can the subject of the complaint (“Respondent”) obtain legal representa�on?
 

3. How long does the inves�ga�ve process take?





 
4. Can the license/cer�ficate holder or applicant work while they are under inves�ga�on?

 

5. What can the subject of the complaint (“Respondent”) or people making the complaint (“Complainant”)
do to assist in the inves�ga�ve process?
h

 

 
Case No.
19


hu
6. What happens when the case is presented to the Board?

e  


7. Who can address the Board members?

e

ou
oae
vhhhe

8. What are 
 
af

 
Dismissal Dismissal oe

Non-Disciplinary 
 


Disciplinary


e
ensure 


au





Case No.
20
alcohol and other drug use along with other requirements. A nurse who l

course, etc.
Suspension eeeriod of


 csher course,
a ar requirements. A

monitoring following sucche terms of suspension.
Revoca�on – he nurse/ccing for a
pursuant to A.A.C. R4-19-404. When a license/certeeen
iard that
nger exists and that the issuanc
would no l-19-404 or R4-19-815) The
re or otherwise
/c
Denial een denied a license/cercate ma not pre
and is not elars.
Voluntary Surrender ,
d their licente.
Administra�ve
Viola�ons
Administra�ve Penalty /cate holder who has

within 30 danot r data centers.
9. When is the Board decision final?
t, a Respondent the
ment” or if not signed, the Respondent has had an opportunit for a
hearing. Hearings are conducted e Hearings and the person conduc

Following the
w and Orde

mine discipline and
determined o
Respondent disagrees with the outcome, a request for rehearing 

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Arizona State Board of Nursing (Arizona State Board of Nursing)

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Completed 27 January 2021

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