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
REQUEST FOR COPY OF INVESTIGATIVE REPORT
I , request a copy of the
Investigative Report regarding the disciplinary action pending against my RN/LPN/CNA/LNA
license/certificate or application for licensure/certification.
I understand the Board may redact (remove) information from the Investigative Report
including:
• patient identifying information
• names of complainants and witnesses who request anonymity
• all privileged information
I understand that a copy of the Investigative Report is provided to me in confidence to help me
understand the Board’s allegations and disciplinary actions being considered against my RN/LPN/CNA/LNA
license/certificate or application for licensure/certification.
I also understand both the Investigative Report and the information in the Report may not be disclosed
or provided to any other person except to an attorney or an attorney’s employee with whom I
have consulted or retained for legal representation in connection with the Board’s possible
disciplinary action.
I understand that, pursuant to A.R.S. § 32-1664 (L) and (M), disclosure of the Investigative
Report or information contained in the Report constitutes a violation of the Nurse Practice
Act and may result in disciplinary action.
APPLICANT/LICENSEE/CERTIFICATE HOLDER’S
SIGNATURE
DATE
CONSULTANT INITIAL:_____________________________
DATE:
