Fill - Free fillable Arizona State Board of Nursing (Arizona State Board of Nursing) PDF form

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)

_________________________________________________________________________

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?

_________________________________________________________________________

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?

_________________________________________________________________________

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?

______________________________________________________________

4

How has this program helped you with your recovery? (be specific)

_________________________________________________________________________

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.

_________________________________________________________________________

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)

_________________________________________________________________________

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)

_________________________________________________________________________

6

_________________________________________________________________________

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)

_________________________________________________________________________

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)

_________________________________________________________________________

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.

_________________________________________________________________________

8

Do you have one primary care provider?

No Yes (if yes, give name and address of provider

_________________________________________________________________________

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?

_________________________________________________________________________

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

CANNABIS

ANABOLIC STEROIDS

List use

Alcohol

THC

Cocaine

Marijuana

Amphetamines

Hashish

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)?

_________________________________________________________________________

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

CANNABIS

ANABOLIC STEROIDS

List use

Alcohol

THC

Cocaine

Marijuana

Amphetamines

Hashish

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)?

_________________________________________________________________________

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) __________________________________________________________

________________________________________________________________________

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)

_________________________________________________________________________

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.

_________________________________________________________________________

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)

_________________________________________________________________________

Have you engaged in illegal activities in order to obtain drugs?

No Yes (if yes, explain)

_________________________________________________________________________

15

Have you ever been arrested for possession of illegal drugs?

No Yes (if yes, explain when, where and disposition of arrest)

_________________________________________________________________________

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.

_________________________________________________________________________

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.

_________________________________________________________________________

What do you like best about being a nurse?

_________________________________________________________________________

17

What do you like least about being a nurse?

_________________________________________________________________________

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.

________________________________

SIGNATURE

SUBSCRIBED AND SWORN to before me this __________________ day of

____________________, 202__.

Commission Expires:

__________________ ________________________________

Date Notary Public

Notary Seal

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