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CALIFORNIA BOARD OF REGISTERED NURSING GENERAL INSTRUCTIONS AND (California)

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
CALIFORNIA BOARD OF REGISTERED NURSING GENERAL
INSTRUCTIONS AND APPLICATION REQUIREMENTS REGARDING THE
PSYCHIATRIC/MENTAL HEALTH (P/MH) NURSE LISTING
GENERAL INSTRUCTIONS
I. Overview
Pursuant to the amendment of Division 2 of the Insurance Code Section 10176, the Board of
Registered Nursing maintains a list of registered nurses who are eligible for direct reimbursement
by some health care plans for providing psychiatric/mental health services to insured persons.
For reimbursement purposes, the psychiatric/mental health services provided must be covered
under the terms of the insured’s plan and must be considered necessary by the referring
physician.
To be eligible for the listing, the California Registered Nurse must possess a master’s degree in
psychiatric/mental health nursing and complete two (2) years of supervised clinical experience in
providing psychiatric/mental health counseling services. The master’s degree in nursing must be
directly
related to mental health, such as psychiatric/mental health nursing or community mental
health nursing.
Validation of the required two (2) years of supervised clinical experience may be obtained in the
following manner: (A) one (1) year of supervised clinical experience obtained while completing
the master’s degree in nursing and one (1) year of supervised clinical experience obtained after
the master’s degree in nursing has been conferred; or two (2) years of supervised clinical
experience obtained subsequent to the conferral of the master’s degree in nursing; or (B)
American Nurses Association - American Nurses Credentialing Center (ANCC) verification as a
Clinical Specialist in Psychiatric/Mental Health Nursing.
Psychiatric/mental health nurses work under the same scope of regulation as do all registered
nurses, and inclusion on the Board’s list does not in any way expand the scope of practice of such
registered nurses.
LIC-A-PMH (REV 1/19) Page 1
GENERAL INSTRUCTIONS (CONT’D)
II. General Application Requirements
Psychiatric/Mental Health Nurse listing eligibility requires the possession of an active California
Registered Nurse (RN) license.
If you do not possess an active California RN license and have never applied for a California RN
licenses, an Application for Licensure by Endorsement must also be submitted. If you have had a
permanent California RN license, you must either renew or reactivate the California RN license.
Nurse Practitioner application fee is nonrefundable. Processing times for certification may vary,
depending on the receipt of documentation from academic programs, association/national
organizations or evaluators. Processing a Nurse Practitioner certification application indicating
disciplinary action(s) and/or voluntary surrender(s) may take longer. A pending application
is not a disclosable public record; therefore, an applicant must sign a release of
information before the Board of Registered Nursing will release information relating to the
application to the public, including employers, relatives or other third parties. Once you are
certified, your address of record must be disclosed to the public upon request.
III. Name and/or Address Changes
California Co
de of Regulations, Section 1409.1 requires that you notify the Board of Registered
Nursing of all name and address changes within thirty (30) days of any change. You may call the
Board of Registered Nursing regarding the change of address of record. If you have changed
your name, please submit a letter of explanation regarding the requested name change plus
applicable documentation such as a copy of a marriage certificate, divorce decree or a driver’s
license.
IV. U.S. Social Security Number and Individual Taxpayer Identification Number (ITIN)
Disclosure of your U.S. Social Security Number/ITIN is mandatory. Section 30 of the Business and
Professions Code and Public Law 94-455 (42 USCA 405 (c)(2)(C)) authorize collection of your U.S. Social
Security Number/ITIN. Your U.S. Social Security Number/ITIN will be used exclusively for tax enforcement
purposes, for purposes of compliance with any judgment or order for family support in accordance
with Section 11350.6 of the Welfare and Institutions Code, or for verification of licensure, certification or
examination status by a licensing or examination entity which utilizes a national examination and where
licensure is reciprocal with the requesting state. If you fail to disclose your U.S. Social Security
Number/ITIN, your application for initial or renewal of licensure/certification will not be
processed. You will be reported to the Franchise Tax Board, who may assess a $100 penalty against you.
ALERT:
Effective July 1, 2012, the Board of Registered Nursing is required to deny an
application for licensure and to suspend the license/certification/registration of any applicant or
licensee who has outstanding tax obligations due to the Franchise Tax Board (FTB) of the State
Board of Equalization (BOE) and appears on either the FTB or BOE’s certified lists of top 500 tax
delinquencies over $100.00. (AB 1424, Perea, Chapter 455, Statues of 2011)
Page 2
LIC-A-PMH (REV 6/20)
GENERAL INSTRUCTIONS (CONT’D)
V. Reporting ALL Discipline(s) and/or Voluntary Surrender(s) Against Licenses/
Certificat
es/Listings
All disciplinary action(s) and/or voluntary surrender(s) against an applicant's psychiatric/
mental health nurse, registered nurse, practical nurse, vocational nurse or other
professional license/certificate/listing must be reported.
Failure to report prior disciplinary action(s) and/or voluntary surrender(s) is
considered falsification of application and is grounds for denial of licensure/
certification/listing or revocation of license/certificate/listing.
When reporting prior disciplinary action(s) and/or voluntary surrender(s), applicants
are required to provide a full written explanation of: circumstances surrounding
the disciplinary action(s) and/or voluntary surrender(s) and the date of disciplinary
action(s) and/or voluntary surrender(s). State board determinations/decisions should also
be included.
NOTE: Applicants must also submit a description of the rehabilitative changes in their
lifestyle which would enable them to avoid future occurrences.
To mak
e a determination
in these cases, the Board of Registered Nursing considers the
nature and severity of the offense, additional subsequent acts, recency of acts or crimes,
compliance with court sanctions and evidence of rehabilitation.
The burden of proof lies with the applicant to demonstrate acceptable documented evidence
of rehabilitation. Examples of rehabilitation evidence include, but are not limited to:
• Recent dated letter from applicant describing rehabilitative efforts or changes in life to
prevent future problems.
• Letters of reference on official letterhead from employers, nursing instructors, health
professionals, professional counselors, parole or probation officers, or
other individuals
in positions of authority who are knowledgeable about your rehabilitation efforts.
• Letters from recognized recovery programs and/or counselors attesting to current
sobriety and length of time of sobriety, if there is a history of alcohol or drug abuse.
• Proof of community work, schooling, self-improvement efforts.
All of the above items should be mailed directly to the Board of Registered Nursing by
the individual(s) or agency who is
providing information about the applicant. Have these
items sent to the Board of Registered Nursing, Licensing Unit – Advanced Practice (P/MH
Listing), P.O. Box 944210, Sacramento, CA 94244-2100.
LIC-A-PMH REV 6/20) Page 3
GENERAL INSTRUCTIONS (CONT’D)
It is the responsibility of the applicant to provide sufficient rehabilitation evidence on
a timely basis so that the listing determination can be made.
An applicant is also required to immediately report, in writing, to the Board of Registered
Nursing any disciplinary action(s) and/or voluntary surrender(s) which occur between the
date the application was filed and the date that a California Psychiatric/Mental Health
listing certificate is issued. Failure to report this
information is grounds for denial of
licensure/certification or revocation of license/certificate.
NOTE: The application must be completed and signed by the applicant under penalty
of perjury.
VI. Address Information
The Board of Registered Nursing’s mailing address is:
Advanced Practice Unit – P/MH Listing
Board of Registered Nursing
P. O. Box 944210, Sacramento, CA 94244-2100
The Board of Registered Nursing’s street address for overnight mail is:
Advanced Practice Unit – P/MH Listing
Board of Regis
tered Nursing
1747 North Market Blvd.
, Suite 150, Sacramento, CA 95834
VII. California Nursing Practice Act
California statutes and regulations pertaining to Registered Nurses - Psychiatric/Mental
Health Nurses may be obtained by contacting:
LexisNexis at:
www.lexisnexis.com/bookstore (search: California Nursing)
APPLICATION REQUIREMENTS FOR
PSYCHIATRIC/MENTAL HEALTH (P/MH) NURSE LISTING
1. The submission of the Application for the Psychiatric/Mental Health Nurse
Listing form (Pages 6 & 7) to the Board of Registered Nursing and applicable fee.
2. Verification of the Completion of a Psychiatric/Mental Health Academic
Program form (Page 8) and official transcripts verifying the master’s degree in
psychiatric/mental health nursing submitted by the academic program directly to the Board of
Registered Nursing. Course descriptions for the applicable period of enrollment should
accompany official transcripts when the nursing specialty area for the master’s degree is not
clearly identified.
LIC-A-PMH (REV 6/20) Page 4
APPLICATION REQUIREMENTS FOR
PSYCHIATRIC/MENTAL HEALTH (P/MH) NURSE LISTING (CONT’D)
3. Submission of one (1) of the applicable forms A (Page 9) or B (Page 10) to the
Board of Registered Nursing to satisfy the supervised clinical experience requirement.
A. Verification of Supervision of Clinical Experience - Page 9
Verification of two (2) years of clinical experience in providing psychiatric/mental health
counseling services under the supervision of one or more of the following professionals with
current training and practice as well as a current, clear and active license:
• A psychiatric/mental health nurse listed with the California Board of Registered Nursing.
• A licensed clinical psychologist.
• A licensed clinical social worker.
• A licensed marriage, family and child counselor.
• A psychiatrist.
The
supervised clinical experience for the provision of psychiatric/mental health counseling
services may be satisfied by evidencing that the required two (2) years of clinical experience
was completed in the following manner:
• One
(1)
year obtained while completing the master’s degree in nursing and one (1) year
after the master’s degree in nursing had been conferred; OR
• Two (2) years obtained subsequent to the conferral of the master’s degree in nursing.
If one professional did not supervise the entire two (2) year period, the verification form must
be submitted by each supervisor to evidence the completion of the required supervised
clinical experience during the two (2) year period. The two (2) year period does not need to
be consecutive years.
Applicants whose experience had been acquired outside of California must provide evidence
that at the time the experience was obtained, the supervisor was currently licensed, certified
or registered to provide psychiatric/mental health counseling services by a state agency
whose standards are equivalent to or greater than those required by the equivalent licensing
agency in California.
B. Verification of Psychiatric/Mental Health Certification by a National
Association - Page 10
American Nurses Association - American Nurses Credentialing Center (ANCC)* verification
that the applicant is currently certified as a Clinical Specialist in Psychiatric/Mental Health
Nursing. The verification form must be submitted directly to the Board of Registered Nursing
by ANCC.
* American Nurses Association - American Nurses Credentialing Center (ANCC)
600 Maryland Ave., SW, Suite 100 West, Washington, DC
20024-2571
(800) 284-2378 http://www.nursingworld.org/ancc
(Above Information Subject to Change)
LIC-A-PMH (REV 1/19) Page 5
VIII.
HONORABLY DISCHARGED MEMBERS OF THE U.S. ARMED FORCES RECEIVE EXPEDITED REVIEW
Notwithstanding any other law, on and after July 1, 2016, a board within the department shall expedite, and may
assist, the initial licensure process for an applicant who supplies satisfactory evidence to the board that the
applicant has served as an active duty member of the Armed Forces of the United States and was honorably
discharged (Business and Professions Code section 115.4
If you would like to be considered for this expedited review and process, please provide the following
documentation with your application:
1. Report of Separation form.
The report of separation form issued in most recent years is the DD Form 214, Certificate of Release or
Discharge from Active Duty. Before January 1, 1950, several similar forms were used by the military services,
including the WD AGO 53, WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD and the NAVCG 553.
Information shown on the Report of Separation may include the service member's date and place of entry into
active duty, date and place of release from active duty, last duty assignment and rank, military job specialty,
military education, total creditable service, separation information, etc.
LIC-A-PMH (REV 1/19)
Page 6
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
APPLICATION FOR THE LISTING AS A PSYCHIATRIC/MENTAL HEALTH (P/MH) NURSE
APPLICATION FEE - $350.00
MILITARY HONORABLE DISCHARGE - Check here if you served as an active duty
member of the Armed Forces of the United States and were hoborably discharged.
A. PERSONAL DATA (Please print or type):
Name:
(Last) ( First) (Middle)
Previous Names (Including Maiden Name):
Address of Record:
( Number & Street)
(City) (State) (Zip Code)
Date of Birth:
(Month) (Day) (Year)
U.S. Social Security Number or Individual Taxpayer
ID Number:
Telephone Number:
Home ( ) Work ( )
E-Mail Address:
B. RN LICENSURE:
California RN License Number: Date Issued: Expiration Date:
List ALL States Where You Hold/Held an RN License and Status:
Original State of RN Licensure:
RN License Number: Date Issued: Expiration Date:
C. RN EDUCATION:
Name of Professional Registered Nursing
Program:
Location:
(City) (State or Country)
Type of RN Program:
ADN DIP BSN MSN
Entrance Date: Graduation/Completion Date:
D. PSYCHIATRIC/MENTAL HEALTH EDUCATION:
Name of Psychiatric/Mental Health Nursing
Academic Program:
Location:
(City) (State or Country)
Entrance Date: Graduation/Completion Date: Nursing Specialty of Master’s Degree:
E. SUPERVISED CLINICAL EXPERIENCE IN PSYCHIATRIC/MENTAL HEALTH COUNSELING:
Beginning and Ending Supervisor’s Name and Briefly Describe the Nature of Your Clinical
Dates: Profession: Experience and State Where It Was Obtained:
LIC-A-PMH (REV 1/19)
Page 7
Name of Association:
Area of Specialization:
F. PSYCHIATRIC/MENTAL HEALTH NURSE PROFESSIONAL CERTIFICATION (If Applicable):
Original Date of Certification:
Certification Number: Current Renewal/Recertification Cycle Dates:
Method of Certification: Examination Other
G. BACKGROUND INFORMATION:
I. Have you ever applied for a Psychiatric/Mental Health Nurse listing in California?
If yes:
Name at Time of Application: ___________________Date Submitted:_______________
Yes No
II. issued a Psychiatric/Mental Health Nurse listing in California?
If yes: STOP. Please contact the Board regarding whether you
should reapply or file a petition for reinstatement of your Psychiatric/Mental Health Nurse
listing.
Have you ever been
DO NOT CONTINUE.
Yes No
III. Have you ever had a health-care related license/certificate/listing to practice nursing
revoked, suspended, placed on probation or otherwise disciplined or voluntarily
surrendered in any way?
If yes, please explain fully as described in the General Instructions - Section V.
Yes No
IV. Have you ever had a professional or vocational license/certificate/listing to practice
revoked, suspended, placed on probation or otherwise disciplined or voluntarily
surrendered in any way?
If yes, please explain fully as described in the General Instructions - Section V.
Yes No
I understand that I am required to report immediately to the California Board of Registered Nursing ANY
disciplinary action and/or voluntary surrender against ANY health-care related license/certificate/listing that
occurs between the date of this application and the date that a California Psychiatric/Mental Health Nurse
listing is issued. I understand that failure to do so may result in denial of this application or subsequent
disciplinary action against my license/certificate/listing.
I certify, under penalty of perjury under the laws of the State of California, that all information provided in
connection with this application for the Psychiatric/Mental Health Nurse listing is true, correct and complete.
Providing false information or omitting required information is grounds for denial of licensure/
certification/listing or licensure/certification/listing revocation in California.
SIGNATURE OF APPLICANT:
NOTE:
PLEASE TAPE A
___________________________________
DATE:_____________________________________________
RECENT 2” x2”
PASSPORT SIZE
PHOTOGRAPH
LIC-A-PMH (REV 6/20)
Page 8
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
VERIFICATION OF THE COMPLETION OF
A PSYCHIATRIC/MENTAL HEALTH (P/MH) ACADEMIC PROGRAM
A. TO BE COMPLETED BY APPLICANT : Please complete Section A and forward to the program director/representative
for the Psychiatric/Mental Health nursing academic program for completion. Official transcripts submitted must include all completed
course work with the master’s degree status conferred and must be sent directly to the Board of Registered Nursing by the
Registrar’s Office/Transcript Office. A processing fee may be required for the submission of the official transcripts. Please print or
type.
Name:
( Last) (First) (Middle)
Previous Names (Including Maiden Name):
Address:
(Number & Street)
(City) (State) (Zip Code)
Date of Birth:
(Month) (Day) (Year)
U.S. Social Security Number or Individual Taxpayer ID Number:
Telephone Number:
Home ( ) Work ( )
California RN License Number:
Expiration Date:
Name of Master’s Degree Nursing Program:
Entrance and Completion Dates: Specialty:
Signature of Applicant:________________________________________Date:__________________
B. TO BE COMPLETED BY THE PROGRAM DIRECTOR/REPRESENTATIVE FOR THE
PSYCHIATRIC/MENTAL HEALTH NURSING ACADEMIC PROGRAM : Please complete Part B regarding the
above named applicant and return to the Board of Registered Nursing.
Name of Master’s Degree Nursing Program: Telephone Number:
( )
Address:
(Number & Street) (City) (State) (Zip Code)
Nursing Specialty: Date Master’s Degree Status Conferred:
Entrance and Completion Dates: From: To:
(Month) (Day) (Year) (Month) (Day) (Year)
I certify under penalty of perjury that the documentation regarding the completion of the Psychiatric/Mental Health
master’s nursing academic program for the above named applicant is true and correct.
Signature:_____________________________________________ Date:_____________________
Title:______________________________________ Telephone Number:(_______)______________
LIC-A-PMH (REV 1/19) Page 9
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
A. VERIFICATION OF SUPERVISION OF CLINICAL EXPERIENCE (P/MH)
A. Please complete Part A of the form and submit
supervisor for completion.
submitted by each supervisor.
INFORMATION TO BE COMPLETED BY THE APPLICANT: to your
If more than one (1) supervisor supervised during the two (2) year period, the form must be
Please print or type.
Name:__________________________________________________________________________________________
(Last)
California RN License Number:
Telephone Number: (________)____________________ U.S. Social Security Number or ITIN:
_____________________
(Middle)(First)
___________________________________ Expiration Date:_____________________
B. Please complete Part B of the form regarding the above
named applicant and submit to the Board of Registered Nursing.
BY SUPERVISOR:INFORMATION TO BE COMPLETED
Name of Supervisor: _____________________________________Telephone Number:
Address: _______________________________________________________________________________________
(Number
Profession: ________________________________Licensed By: ___________________________________________
License Number: ___________Expiration
(________)_______________
(Zip Code)(State)(City)& Street)
Date:______________ U.S. Social Security Number: _____________________
Location of Clinical
(Name of
Level of Supervision Provided:_______________________________________________________________________
Summary of the nature of cases, types of treatment and/or appropriate interventions carried out by the above named
applicant during the specified period of supervision for the provision of psychiatric/mental health counseling services:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
______________________________________________________________________
I hereby certify under penalty of perjury that the above is true and correct and that I supervised the above named applicant
in providing psychiatric/mental health counseling services to clients during the period:
From:___________________ To:___________________ For:____________ Hours Per Week
Month)
Signature of Supervisor:__________________________________________________Date: _____________________
Experience:_____________________________________________________________________
(Address)Agency)
= _________________.
(Cumulative Hours)(Number of)(Year)(Day)(Month)(Year)(Day)
LIC-A-PMH (REV 1/19) Page 10
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
B. VERIFICATION OF PSYCHIATRIC/MENTAL HEALTH (P/MH) CERTIFICATION
BY A NATIONAL ASSOCIATION
A. TO BE COMPLETED BY APPLICANT: Please complete Part A and submit to the American Nurses
Association - American Nurses Credentialing Center (ANCC) to verify your clinical specialist in psychiatric/mental health
nursing certification status. A fee is required by ANCC for processing the verification form. Please print or type.
Name:
( Last) (First) (Middle)
Previous Names (Including Maiden Name):
Address:
(Number & Street)
(City) (State) (Zip Code)
Date of Birth:
(Month) (Day) (Year)
U.S. Social Security Number or Individual Taxpayer ID Number:
Telephone Number:
Home ( ) Work ( )
California RN License Number:
Expiration Date:
Name of Master’s Degree Nursing Program:
Entrance and Completion Dates: Specialty:
Signature of Applicant:________________________________________Date:__________________
B. TO BE COMPLETED BY THE CERTIFYING NATIONAL ASSOCIATION: Please complete Part B
regarding the above named applicant and return to the Board of Registered Nursing.
Name of Certifying National Association: Telephone Number:
( )
Address:
(Number & Street) (City) (State) (Zip Code)
Method of Certification:
Certificate Number:
Original Date of Certification:
CNS Certification Specialty:
Current Renewal Cycle Dates for Certification/Recertification:
From: To:
(If not applicable, please explain.) (Month) (Year) (Month) (Year)
I certify under penalty of perjury that the clinical specialist in psychiatric/mental health nursing certification status
for the above named applicant is true and correct.
Signature:____________________________________________Date:________________________
Title:_______________________ Telephone Number:(_____)_____________ (OFFICIAL SEAL)
LIC-A-PMH (REV 1/19) Page 11
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BOARD OF REGISTERED NURSING
PO Box 944210, Sacramento, CA 94244-2100
P (916) 322-3350 l www.rn.ca.gov
INFORMATION COLLECTION AND ACCESS
The Information Practices Act, Section 1798.17 Civil Code, requires the following information to be
provided when collecting information from individuals.
Agency Name:
BOARD OF REGISTERED NURSING
Title of official responsible for information maintenance:
EXECUTIVE OFFICER
Address: Telephone Number:
P.O. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350
Authority which authorizes the maintenance of the information:
SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODE
ALL INFORMATION IS MANDATORY.
The consequences, if any of not providing all or any part of the requested information:
FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE
APPLICATION BEING REJECTED AS INCOMPLETE.
The principal purpose(s) for which the information is to be used:
TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBER/ITIN
WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT
AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE
BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USCA 405(c)(2)(C))
AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TO
DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER/ITIN, YOU WILL BE REPORTED TO THE
FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR
NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC
UPON REQUEST IF AND WHEN YOU BECOME LICENSED.
Any known or foreseeable interagency or intergovernmental transfer which may be made of the
inform
ation:
POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND
REPORTING U.S. SOCIAL SECURITY NUMBER/ITIN TO THE FRANCHISE TAX BOARD OR
FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE
BUSINESS AND PROFESSIONS CODE.
EACH INDIVIDUAL HAS THE RIGHT TO REVIEW THE FILES ON RECORDS MAINTAINED ON
THEM BY THE AGENCY, UNLESS THE RECORDS ARE EXEMPT FROM DISCLOSURE.
(Rev 1/19) 1
MANDATORY REPORTER
Under California law each person licensed by the Board of Registered Nursing is a “Mandated
Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and
as a prerequisite to that employment, all mandated reporters must sign a statement on a form
provided to him or her by his or her employer to the effect that he or she has knowledge of the
provisions of Section 11166 and will comply with those provisions.
California Penal Code Section 11166 requires that all mandated reporters make a report to an
agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever
the mandated reporter, in his or her professional capacity or within the scope of his or her
employment, has knowledge of or observes a child whom the mandated reporter knows or
reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must
make a report to the agency immediately or as soon as is practicably possible by telephone, and
the mandated reporter must prepare and send a written report thereof within 36 hours of receiving
the information concerning the incident.
Failure to comply with the requirements of Section 11166 is a misdemeanor, punishable by up to
six months in a county jail, by a fine of one thousand dollars ($1,000), or by both imprisonment
and fine.
For further details about these requirements, consult Penal Code Section 11164, and subsequent
sections.
(Rev 1/19) 2
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