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
Re: , Case No.
QUESTIONNAIRE DUE BY:
Attn: ,
PLEASE PRINT IN INK OR TYPE
THIS QUESTIONNAIRE WILL NOT BE ACCEPTED IF FILLED OUT IN PENCIL
Take time to read each question carefully and then answer it to the best of your knowledge. Do
not leave any questions unanswered. Attach additional sheets, if necessary. The questionnaire
will be returned to you if it is not filled out appropriately.
NAME: DATE:
ADDRESS:
PHONE: HOME ( ) WORK: ( )
RN #: ___________ LPN #: ___________ NP CERTIFIED #: ________________
R E C O V E R Y H I S T O R Y
Have you completed a drug/alcohol rehabilitation program?
No Yes (if yes, complete the following)
Inpatient Outpatient
Date of entry: ____________ Date of completion: ____________
Send documentation of proof of completion
2
Have you completed an aftercare program?
No Yes (if yes, complete the following)
Date of entry: ____________ Date of completion: ____________
Send documentation of proof of completion
Have you participated in a nurse recovery group?
No Yes (if yes, complete the following)
When did you join the nurse recovery group? _________________
Name of the group facilitator: ____________________________
(Have facilitator send documentation with date of entry, attendance, certification and
progress)
How often do you attend the group? ________________________
How has the group helped you with your recovery? (be specific)
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3
Have you participated in a twelve-step program (AA or NA)?
No Yes (if yes, complete the following)
When did you begin your twelve-step program? ________________
How often do you attend meetings? Weekly More than once a week Monthly
Other ______________
Do you have a home group?
No Yes (if yes, complete the following)
Name of Home Group: _______________________________________
Do you have a sponsor? No Yes (if yes, complete the following)
How long have you had this sponsor? _______________________
How often do you meet and/or have contact with your sponsor?
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Have your current sponsor write a letter to the Board addressing the length of time he/she
has been your sponsor, addressing your twelve-step activities and their general impression
of your recovery status. The Board respects the twelve-step anonymity and the sponsor
letter then need only be signed with their first name. If your sponsor is willing to release
their phone number, ask them to submit it.
How many sponsors have you had within the last three years?
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Have you completed the twelve steps? No Yes
(If "No" what step are you on?) _________________________________________
Have you read the Big Book? No Yes
If you have not completed reading the Big Book, what chapter are you on?
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4
How has this program helped you with your recovery? (be specific)
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If you have not participated in a twelve-step program, have you participated in an alternative
program such as Rational Recovery or any other program?
No Yes (if yes, complete the following)
Briefly describe the function of the program and how it has benefited you in recovery.
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5
Since you have had your license, have you had any drug screens?
No Yes (if yes, submit copies of results of drug testing)
Since you have had your license, have you been evaluated by an addictionist?
No Yes (if yes, send documentation)
Evaluations by an addictionist must include a complete history and physical, laboratory
test and an interview evaluation.
Since you have had your license, have you been evaluated by a relapse prevention counselor?
No Yes (if yes, send documentation)
If yes, what are your relapse warning signs? (be specific)
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Since you have had your license, have you had any counseling for your substance abuse
problem?
No Yes (if yes, send documentation)
Describe your recovery program (include your support system)
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7
M E D I C A L H I S T O R Y
Describe any current acute or chronic medical problems (include hospitalization, surgery,
fractures, accidents, dental work, emergencies (give dates; be specific)
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Describe any acute or chronic medical problems occurring during the past five years
(include hospitalization, surgery, fractures, accidents, dental work, emergencies (give
dates; be specific)
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List all current prescription, self-prescribed and over-the- counter medications. For
prescription medication, list name of the prescribing provider, name of medication, reason
for medication, date of prescription.
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8
Do you have one primary care provider?
No Yes (if yes, give name and address of provider
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Does the above provider know of your chemical dependency?
No Yes
If you are currently on any narcotics, non-narcotic analgesics, hypnotics, or any mood-
altering medications, have the provider who prescribed write a letter to the Board stating
reason for prescription, length and expected use, and addressing their knowledge of your
chemical dependence.
How would you describe your current health status?
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9
C U R R E N T S U B S T A N C E A B U S E H I S T O R Y (legal and/or illegal)
Current alcohol and/or drug use (check all that are applicable)
STIMULANTS
INHALANTS
List use
ANABOLIC STEROIDS
List use
Alcohol
Cocaine
Amphetamines
Nicotine
Caffeine
NARCOTIC ANALGESICS:
codeine based
methadone
fentanyl (sublimaze)
darvon
morphine
talwin
demerol
opium
tylox
dilaudid
percocet
vicodan
heroin
percodan
other (specify)
NON-NARCOTIC ANALGESICS:
nubain stadol other (specify)
HYPNOTICS:
chloral hydrate (noctec) halcion
soma phenobarbital nembutal
other (specify)
ANTI-ANXIETY:
ativan tranxene xanax
librium valium other (specify)
HALLUCINOGENS:
LSD PCP STP MOA
Mescaline other (specify)
What was your drug(s) of choice (including alcohol)?
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10
P A S T S U B S T A N C E A B U S E H I S T O R Y (legal and/or illegal)
Past alcohol and/or drug use (check all that are applicable)
STIMULANTS
INHALANTS
List use
ANABOLIC STEROIDS
List use
Alcohol
Cocaine
Amphetamines
Nicotine
Caffeine
NARCOTIC ANALGESICS:
codeine based
methadone
fentanyl (sublimaze)
darvon
morphine
talwin
demerol
opium
tylox
dilaudid
percocet
vicodan
heroin
percodan
other (specify)
NON-NARCOTIC ANALGESICS:
nubain stadol other (specify)
HYPNOTICS:
chloral hydrate (noctec) halcion
soma phenobarbital nembutal
other (specify)
ANTI-ANXIETY:
ativan tranxene xanax
librium valium other (specify)
HALLUCINOGENS:
LSD PCP STP MOA
Mescaline other (specify)
What was your drug(s) of choice (including alcohol)?
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11
How were the drugs listed on pages 9-10 obtained? (be specific)
prescription abuse No Yes
diversion No Yes
street purchase No Yes
writing your own Rx No Yes
presenting illegal Rx No Yes
other (explain) __________________________________________________________
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How long have you been clean of prescription or illegal drugs?
_____________days _____________months _____________years
How long have you been sober?
_____________days _____________months _____________years
Do you smoke cigarettes and/or have any other tobacco usage?
No Yes (if yes, describe use)
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OTHER ADDICTIONS (if in current or past counseling for any, send documentation)
food shopping shoplifting
relationships gambling sex
other none of the above
12
E M P L O Y M E N T H I S T O R Y:
Name of Employer:
Employer’s Address:
Job title:
Supervisor:
Phone No.:
Date of Hire:
Is supervisor aware of your substance abuse problem? No Yes
If you are currently employed, have your supervisor write a letter on their letterhead
stationery to the Board addressing the length of time of your employment, attendance
record, and their general evaluation of your performance. (If you have been employed by
more than one agency within the last 18 months, have each supervisor write to the Board
as instructed above.
List the places you have been employed for the past 3-5 years.
1. Name of Employer:
Employer’s 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. Name of Employer:
Employer’s Address:
Job title:
Supervisor:
Phone No.:
Start Date: End Date:
13
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. Name of Employer:
Employer’s 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:
L E G A L H I S T O R Y (current and past)
In the past, or currently, have you been on civil or criminal probation?
No Yes (if yes, briefly explain reason for probation).
Also have your probation office write a letter to the Board stating the reason for your
probation, length of time and your compliance with your probation requirements.
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14
Have you ever been arrested while driving under the influence of drugs and/or alcohol?
No Yes (if yes, explain when, where and disposition of arrest)
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Have you engaged in illegal activities in order to obtain drugs?
No Yes (if yes, explain)
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15
Have you ever been arrested for possession of illegal drugs?
No Yes (if yes, explain when, where and disposition of arrest)
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L I C E N S E I N F O R M A T I O N:
Have you ever had any disciplinary action on your license in Arizona or any other state?
No Yes ___
If yes, briefly explain why for each state in which the discipline occurred and the current
disposition of your license in that state.
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16
If there is a current complaint with the Arizona State Board of Nursing against your license, give
a brief summary and describe your version of the events of the complaint.
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What do you like best about being a nurse?
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17
What do you like least about being a nurse?
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AFFIDAVIT
STATE OF _________________________
County of ________________________
The undersigned being duly sworn declares that he/she is the person referred to in the foregoing
application; that the statements are true in every respect; that he/she has not suppressed any
information that would affect this application: that he/she will conform to the ethical standards
of conduct in the profession of nursing; and that he/she has read and understands this affidavit.
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SIGNATURE
SUBSCRIBED AND SWORN to before me this __________________ day of
____________________, 202__.
Commission Expires:
__________________ ________________________________
Date Notary Public
Notary Seal