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
REQUEST FOR COPY OF INVESTIGATIVE REPORT
I _____________________, request a copy of the Investigative Report regarding the disciplinary action
pending against my
I understand the Board reserves the right to redact the following information from the Investigative
Report:
patient identifying information
information received directly from the FBI RAP sheet, if any
names of complainants and witnesses who request anonymity
I understand that a copy of the Investigative Report is provided to me in confidence to assist in my
defending the disciplinary action against my , and that the information therein 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 disciplinary
action.
I understand that, pursuant to A.R.S. § 32-1664 (L) and (M), disclosure of the information contained in
the Investigative Report constitutes a violation of the Nurse Practice Act and may result in disciplinary
action.
Request copy to be sent by Secure E-mail to:
LICENSEE/CERTIFICATE HOLDER’S SIGNATURE
DATE
CONSULTANT INITIAL: ( ) (Case No. )
DATE:
