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
1
ARREST/CHARGE/CITATION QUESTIONNAIRE
ATTN: ,
Re: (Case No. )
Instrucons:
• A completed re MUST BE submed for EACH rrest, chrge, or c you ve ever receved, regrdless of
 or outcome (excl c  DUIs, Reckless g,   d  ts   dered c tr
mldets (excepteed evey wery 
• ey the qureed order to pspt
•    or t R   efully  swer every  “See ed”    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 wen statement Pr of your  wll be ded d dd
res  be se  t     submed    d for every ,
chrge, or cto, regrdless of ge or outcome Flure to pde the rred documets  be cdered re to
th they sute he Nu
e Act
1. Demographic Informaon:
Full Nme: __________________________________________________________________________________
Frst ddle Lst
All Other/Former N______________________________
___________________________________________________________________________________________
ecurty Number: ________________________rth: __________________________________
Address: ____________________________________________________________________________________
Street Cty Stte Zp
e Number: __________________________ Cell/Moble Number: _____________________________
2. Arreon Infor
lo restyo
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
Revised 09/2016
2
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.
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:______________________________________________________________________________
3
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.
4.EmploymentInformation
Fillinyouremploymentinformationforcurrentandpastemploymentforthepastfiveyears.(Ifyouhavenotaccounted
forfiveyearsofemploymentbelow,addadditional/previousemployersonaseparatepageandincludeallfieldsbelow.)
CurrentEmployer(s)
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
PreviousEmployer(s)
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
Wereyouterminatedordidyouresigninlieuoftermination?
Yes No
Ifyes,pleaseexplainornoteyourreasonforleaving: _________________________________________
Revised 09/2016
4
Employer: __________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Phone Number: _______________________ Posion/Title: _________________________________________________
Start Date: __________________________ End Date: _________________________
Supervisor’s Name: _____________________________________ Supervisor’s Phone Number: _____________________
Were you terminated or did you resign in lieu of on?
Yes No
If yes, please explain or note your reason for leaving: _________________________________________
5. 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.
5a) 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.
5b)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: /
click to sign
signature
click to edit
5
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.
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.
Revised 09/2016
6
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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
7
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Respondentmust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 27 January 2021

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