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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1
Doug Ducey Joey Ridenour
Governor Executive Director
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
AP/RN/LPN INVESTIGATIVE QUESTIONNAIRE
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:
Primary State of Residence (Where you vote, pay
federal taxes, current driver’s license):
Address:
Telephone Numbers:
Home:
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?
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.:
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
If yes, please explain or note your reason for leaving:
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
If yes, please explain or note your reason for leaving:
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
If yes, please explain or note your reason for leaving:
4. Were you terminated or did you resign in lieu of termination from any previous employment? Yes No
If yes, please provide an explanation:
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).
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.
Name
Address
Phone No.
Work Relationship
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
10. Do you have any previous discipline history by a board of nursing?
Select one of the answers below.
6
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.)
Unknown (If you select this option, do not select any other choices)
7
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
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 specifiy
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
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
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
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
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
Dosage form confusion
Reconciliation material confusing/inaccurate
13
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
14
VI. ARRESTS/CONVICTIONS
Do you have any arrests/convictions? 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.
______________________________________ ______________________________
Signature Date
Thank you for your assistance. Please return to:
Attention:
Arizona State Board of Nursing
1740 N. Adams
Street, Suite 2000
Phoenix, Arizona 85007-2607
15
ARREST/CHARGE/CITATION QUESTIONNAIRE
Instructions:
A completed questionnaire MUST BE submitted for EACH arrest, charge, or citation you have ever received, regardless of
age or outcome (excluding civil traffic. DUIs, Reckless Driving, or Hit and Run incidents are not considered civil traffic).
This means incidents must be disclosed even if they were ultimately dismissed.
Make as many copies of the questionnaire as you need in order to submit a separate questionnaire per incident.
Please print neatly or type. Read each question carefully and answer every question. “See attached” is not an acceptable
answer.
Complete and submit ALL pages of the questionnaire, sign and date the last page, and attach the required police and
court records as well as your detailed written statement. Processing of your case will be delayed and additional
questionnaires will be sent if this required information is not submitted with each questionnaire and for every arrest,
charge, or citation, regardless of age or outcome. Failure to provide the required documents may be considered failure to
cooperate with the Board investigation and may constitute a violation of the Nurse Practice Act.
1. Demographic Information:
Full Name: __________________________________________________________________________________
First Middle Last
All Other/Former Names Used or Aliases (maiden, prior married names): ________________________________
___________________________________________________________________________________________
Social Security Number: _________________________ Date of Birth: __________________________________
Address: ____________________________________________________________________________________
Street City State Zip
Home Phone Number: __________________________ Cell/Mobile Number: _____________________________
2. Arrest/Charge/Citation Information:
Fill in the following information regarding the agency which arrested or cited you.
Name of law enforcement agency or sheriff office: ____________________________________________
Address of agency: _____________________________________________________________________
Street City State Zip
Date arrested/charged/cited: ______________________
For what offense(s) were you arrested, charged or cited? _____________________________________________
Was the arrest/charge/citation for: misdemeanor felony
I have requested from this law enforcement agency and am submitting with this questionnaire, as applicable, ALL
required police records listed below:
Arrest/booking report, complaint, citation/ticket if applicable AND
Officer narrative, arrest/incident department report. The narrative explains why the officer made contact
with you and what occurred during that contact AND
All supplements or additions to the report, including results of testing, additional information, etc.
I am submitting with this questionnaire my detailed written (or typed) statement regarding the circumstances
surrounding this arrest, charge or citation.
When submitting a written explanation, be sure to be as specific as possible and address the “who, what, when, where,
why and how” of the circumstances regarding the incident. This is your opportunity to tell the Board what happened in
your own words. Failure to provide a detailed statement regarding each incident is a violation of the Nurse Practice Act.
16
3. Court Information:
Fill in the following information regarding the court where your case was heard or where your charges were submitted,
if applicable.
Name of Court: ________________________________________________________________________
Address of Court: ______________________________________________________________________
Street City State Zip
Of what offense(s) were you convicted?___________________________________________________________
Date of conviction: ______________________
Was the conviction: misdemeanor felony undesignated
Did you plead: guilty nolo contendere no contest
What was the sentence? (Include all fines, courses, counseling or group sessions, restitution, probation/parole,
community service, etc)
___________________________________________________________________________________________
___________________________________________________________________________________________
If the conviction was for a felony or undesignated offense, what was the date of completion of all probation
requirements, including payment of court fines and restitution (You must include proof of completion of
probation/court requirements/payment in full)? _____________________
Has there been any change in the designation of your conviction since the original sentencing (Examples: reduced to a
misdemeanor, set aside, dismissed, expunged, deferred)?
No Yes
If yes, what was the change? _____________________________________________________________
Are you currently on probation or parole? No Yes
If yes, when is your anticipated probation or parole end/discharge date? __________________________
Name of your probation/parole officer (PO): __________________________
Probation/parole officer phone number: _________________________
Were you ever found in violation of your probation or was a warrant ever issued? No Yes
If so, describe the circumstances of the violation: ____________________________________________
_____________________________________________________________________________________
Was your sentence modified as a result of your probation violation? No Yes
Explain: ______________________________________________________________________________
I have requested from this court and am submitting with this questionnaire, as applicable, ALL required court records
listed below:
Notice of charges, complaint, indictment. This will show the Board what you were originally charged with;
AND
Pre-sentence screening, report or referral, pre-sentence report AND
Plea agreement/s if applicable AND
Sentencing, probation order/judgment. This will show the requirements imposed by the court AND
Dismissal, probation release, court discharge.
17
4. Document Requirements
Check off the boxes below to ensure you have provided all documentation required to be submitted with this
questionnaire.
A Detailed Written (or Typed) Statement.
ALL Police, Sheriff, or Law Enforcement Records.
ALL Court Documents.
4a) If no formal court charges resulted from the arrest or citation, you must still include the police report. However, in place
of the court records listed above, please provide:
Documentation or letter from the police department or court stating that no charges were filed or that
prosecution was declined.
4b) If the arrest, citation or charge occurred several years ago and police or court records have been purged or are no longer
available, a document on letterhead from the police department and court stating 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 information provided by me and answered within this questionnaire is true, complete and correct,
and I have disclosed each of my arrests, citations and charges, for felonies and misdemeanors, including incidents that did
not ultimately result in convictions.
__________________________________________________________ _________________________
Signature Date
18
Complaint or Self-Report Process
http://azbn.gov/faqs/discipline-complaints/submitting-a-complaint-faqs/
1. What happens with the complaint?
When a complaint or self-report is received by the Board, it is first reviewed to determine jurisdiction. If the
Board has jurisdiction, an investigator and a case number are assigned. Notification letters are sent to the
complainant and to the subject of the complaint and the investigative process begins. The subject of the
complaint (“Respondent”) is made aware of the specific allegations and is required to respond in writing. The
investigator collects objective information from a number of sources, interviews the complainant, witnesses,
and Respondent. The information is compiled into an investigative report to present at a board meeting for
the Boards’ review and decision. The board meeting is open to the public. The complainant and Respondent
may choose to be present and make a statement to the Board but neither is required to do so. The board
meeting is not a hearing but rather is forum for the Board to determine, based upon the investigative findings,
if probable evidence exist that a license or certificate holder has violated the Nurse Practice Act.
2. Can the subject of the complaint (“Respondent”) obtain legal representation?
At any stage of the investigative process, the subject of the complaint (“Respondent”) may obtain
independent legal representation.
3. How long does the investigative process take?
Several factors weigh into how long an investigation may take before the case is presented to the Board. The
Board considers the severity of the risk to the public first and foremost and prioritizes accordingly. Some case
are much more complex than others and take longer to process. If the allegation meets the criteria for case
opening, both the complainant and Respondent receive notification that an investigation is in process and
provided with contact information for the assigned investigator. We encourage you to stay in contact with the
investigator throughout the process to facilitate the investigation.
4. Can the license/certificate holder or applicant work while they are under investigation?
The ability to work as a nurse, LNA or CNA is unrestricted during the investigation as long as the license or
certificate remains active. However, applicants are not issued a license/certificate until the conclusion of the
investigation and therefore cannot work until a license/certificate has been issued.
5. What can the subject of the complaint (“Respondent”) or people making the complaint (“Complainant”)
do to assist in the investigative process?
If you are the subject of the complaint (“Respondent”): keep the board apprised of any changes in your
address and phone number, and respond promptly to any requests for information or documents. You will be
required to submit a written response to the complaint and will be requested to meet with the assigned
investigator for an interview and to review information obtained during the course of the investigation. Your
input and participation is important in understanding what occurred.
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If you have filed a complaint (“Complainant”): submit all written documentation regarding your concerns,
observations and impressions concerning the incident. Providing detailed information at the onset is
important in assisting the Board to understand risk of harm and in facilitating the investigative process.
6. What happens when the case is presented to the Board?
The board meeting is an open public meeting where investigative reports related to complaints that have been
received and investigated by staff are reviewed by the Board members to determine, based upon evidence in
a case, whether there is probable evidence of a violation of the Nurse Practice Act. Board members will
deliberate and make a motion, stating what action should occur.
7. Who can address the Board members?
If you have submitted a complaint (“Complainant”) or you have had a complaint submitted against your
application or your license/certificate (“Respondent”), you are welcome to attend the board meeting to hear
the discussion and Board decision. The board meeting is not a hearing but you may choose to give a verbal
presentation (up to 5 minutes), providing information you feel is pertinent for the Board to consider. You may
also choose to just be available to respond to their questions, or you may be present and not speak at all.
Information that is relevant to the complaint and investigation should have been provided to the assigned
investigator in advance of the board meeting.
8. What are the possible Board members decisions or actions?
Board actions are categorized as: Dismissal, Non-disciplinary Action, Disciplinary Action, and Administrative
Violations. Once the case has been reviewed by the Board and the Board votes for discipline, the
licensee/certificate holder/applicant status is updated to reflect "complaint-outcome pending" or if final, the
disciplinary action taken.
Dismissal
Dismissal – Evidence does not support there has been a violation of the Nurse Practice
Act.
Non-Disciplinary
Letter of Concern – A letter from the Board expressing concern that a licensee, certificate
holder or applicant may have been engage in questionable conduct that is considered low
risk or harm to the public. A letter of concern issued by the Board is non-discipline and is
not an appealable agency action
Disciplinary
Actions
Civil Penalty – A monetary fine issued by the Board, not to exceed $1,000, given singly or
in combination with any disciplinary action for a violation of the Nurse Practice Act.
Decree of Censure – This is an official discipline by the Board that the individual’s conduct
violated the Nurse Practice Act but does not represent a continued risk to the
patient/public.
Probation – This action allows the nurse to continue working during the period of
probation subject to compliance with the terms and conditions. During the period of
probation the nurse must be supervised in their practice and complete certain
requirements which are aimed at rehabilitation or educating and remediating the nurse in
his/her area(s) of practice deficit. For example, a nurse with a substance abuse issue may
be required to enter and complete treatment, attend AA/NA meetings, abstain from
20
alcohol and other drug use along with other requirements. A nurse who lacks sufficient
knowledge of medications or safe administration may be required to take a pharmacology
course, etc.
Suspension – A person who has been suspended may not practice during the period of
suspension. A person who has been suspended has terms and conditions which must be
fulfilled during the period of suspension and before being allowed to resume practice.
Examples of terms and conditions may include completing a refresher course,
psychological or substance abuse treatment in addition to other requirements. A
licensee/certificate holder that has been suspended often has a period of probation or
monitoring following successful completion of the terms of suspension.
Revocation – This action prohibits the nurse/certificate holder from practicing for a
minimum of five years, pursuant to A.A.C. R4-19-404. When a license/certificate has been
revoked, the applicant for re-issuance must provide detailed information to the Board that
the reason for revocation no longer exists and that the issuance of a license/certificate
would no longer threaten the public health or safety. A.A.C. R4-19-404 or R4-19-815) The
individual whose license/certificate has been revoked may not practice or otherwise
indicate to the public that they hold a license/certificate.
Denial – A person (applicant) who has been denied a license/certificate may not practice
and is not eligible to reapply to the Board for a period of five years.
Voluntary Surrender – A Consent Agreement has been signed in which an APRN, RN, LPN,
LNA, CNA has voluntarily surrendered their license or certificate.
Administrative
Violations
Administrative Penalty – A penalty/fine given to a licensee or certificate holder who has
worked on an expired license/certificate, or failed to notify the Board of an address change
within 30 days. It is not reportable to NCSBN or other national data centers.
9. When is the Board decision final?
For discipline to be final and in effect, a Respondent must either consent to the discipline as voted upon by the
Board by signing a “Consent Agreement” or if not signed, the Respondent has had an opportunity for a
hearing. Hearings are conducted at the Office of Administrative Hearings and the person conducting the
Hearing is an Administrative Law Judge (ALJ).
Following the hearing and based upon the evidence presented, the ALJ submits recommended “Findings of
Fact, Conclusions of Law and Order” to the Board. Transcripts of the hearing are reviewed by the Board
members prior to voting on the appropriate disciplinary actions (if any) to be taken. The Board has final
authority to determine discipline and can adopt, modify or reject the ALJ recommendation. If discipline is
determined to be appropriate by the majority of the Board Members, a “Board Order” is issued. If the
Respondent disagrees with the outcome, a request for rehearing must be filed within 30 days of the mailing of
the Board’s decision and Order, otherwise, the matter is final.
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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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