Fillable Form 607: a Stat ing of Nurs e (Arizona State Board of Nursing)

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Form 607: a Stat ing of Nurs e (Arizona State Board of Nursing)

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The Form 607: a Stat ing of Nurs e (Arizona State Board of Nursing) form is 6 pages long and contains:

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  • 14 check-boxes
  • 115 other fields

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File type: PDF

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2. Briefly describe what actions you have taken since the surrender/revocation of your license/certificate that
would ensure the Board that these circumstances would not occur again: (Please attach any supporting
documents that you have)
3. Has any other state taken action on your license/certificate as a result of the surrender/revocation by the
Arizona State Board of Nursing? If yes, describe circumstances.
ARREST/CHARGE/CITATION QUESTIONNAIRE
Re: (Case No. )
Instruc�ons:
AcompletedquestionnaireMUSTBEsubmittedforEACHarrest,charge,orcitationyouhaveeverreceived,regardlessof
ageoroutcome(excluding civiltraffic.DUIs,RecklessDriving, or Hit andRunincidentsarenotconsideredciviltraffic).
Thismeansincidentsmustbedisclosedeveniftheywereultimatelydismissed.
Makeasmanycopiesofthequestionnaireasyouneedinordertosubmitaseparatequestionnaireperincident.
Pleaseprintneatlyortype.Readeachquestioncarefullyandanswereveryquestion.“Seeattached”isnotanacceptable
answer.
CompleteandsubmitALLpagesofthequestionnaire,signanddatethelastpage,andattachtherequiredpoliceand
courtrecordsaswellasyourdetailedwrittenstatement. Processing of your case will be delayed and additional
questionnaires will be sent if thisrequired information is not submitted witheach questionnaire and for every arrest,
charge,orcitation,regardlessofageoroutcome.Failuretoprovidetherequireddocumentsmaybeconsideredfailureto
cooperatewiththeBoardinvestigationandmayconstituteaviolationoftheNursePracticeAct.
1.DemographicInformation:
FullName:__________________________________________________________________________________
FirstMiddleLast
AllOther/FormerNamesUsedorAliases(maiden,priormarriednames):________________________________
___________________________________________________________________________________________
SocialSecurityNumber:_________________________DateofBirth:__________________________________
Address:____________________________________________________________________________________
StreetCityStateZip
HomePhoneNumber:__________________________Cell/MobileNumber:_____________________________
2.Arrest/Charge/CitationInformation:
Fillinthefollowinginformationregardingtheagencywhicharrestedorcitedyou.
Nameoflawenforcementagencyorsheriffoffice:____________________________________________
Addressofagency:_____________________________________________________________________

StreetCityStateZip
Datearrested/charged/cited:______________________
Forwhatoffense(s)wereyouarrested,chargedorcited?_____________________________________________
Wasthearrest/charge/citationfor:
misdemeanor felony
Ihaverequestedfromthislawenforcementagencyandamsubmittingwiththisquestionnaire,asapplicable,ALL
requiredpolicerecordslistedbelow:
Arrest/bookingreport,complaint,citation/ticketifapplicableAND
Officernarrative,arrest/incidentdepartmentreport.Thenarrativeexplainswhytheofficermadecontact
withyouandwhatoccurredduringthatcontactAND
Allsupplementsoradditionstothereport,includingresultsoftesting,additionalinformation,etc.
Iamsubmittingwiththisquestionnairemydetailedwritten(ortyped)statementregardingthecircumstances
surroundingthisarrest,chargeorcitation.
Whensubmittingawrittenexplanation,besuretobeasspecificaspossibleandaddressthe“who,what,when,where,
whyandhow”ofthecircumstancesregardingtheincident.ThisisyouropportunitytotelltheBoardwhathappenedin
yourownwords.FailuretoprovideadetailedstatementregardingeachincidentisaviolationoftheNursePracticeAct.
3.CourtInformation:
Fillinthefollowinginformationregardingthecourtwhereyourcasewasheardorwhereyourchargesweresubmitted,
ifapplicable.
NameofCourt:________________________________________________________________________
AddressofCourt:______________________________________________________________________

StreetCityStateZip
Ofwhatoffense(s)wereyouconvicted?___________________________________________________________
Dateofconviction:______________________
Wastheconviction:
misdemeanor felony  undesignated
Didyouplead:
guilty nolocontendere nocontest
Whatwasthesentence?(Includeallfines,courses,counselingorgroupsessions,restitution,probation/parole,
communityservice,etc)
___________________________________________________________________________________________
___________________________________________________________________________________________
Iftheconvictionwasforafelonyorundesignatedoffense,whatwasthedateofcompletionofallprobation
requirements,includingpaymentofcourtfinesandrestitution(Youmustincludeproofofcompletionof
probation/courtrequirements/paymentinfull)?_____________________
Hastherebeenanychangeinthedesignationofyourconvictionsincetheoriginalsentencing(Examples:reducedtoa
misdemeanor,setaside,dismissed,expunged,deferred)?
No Yes
Ifyes,whatwasthechange?_____________________________________________________________
Areyoucurrentlyonprobationorparole?
No Yes
Ifyes,whenisyouranticipatedprobationorparoleend/dischargedate?__________________________
Nameofyourprobation/paroleofficer(PO):__________________________
Probation/paroleofficerphonenumber:_________________________
Wereyoueverfoundinviolationofyourprobationorwasawarranteverissued?
No Yes
Ifso,describethecircumstancesoftheviolation:____________________________________________
_____________________________________________________________________________________
Wasyoursentencemodifiedasaresultofyourprobationviolation?
No Yes
Explain:______________________________________________________________________________
Ihaverequestedfromthiscourtandamsubmittingwiththisquestionnaire,asapplicable,ALLrequiredcourtrecords
listedbelow:
Noticeofcharges,complaint,indictment.ThiswillshowtheBoardwhatyouwereoriginallychargedwith;AND
Pre‐sentencescreening,reportorreferral,pre‐sentencereport;AND
Pleaagreement/sifapplicable;AND
Sentencing,probationorder/judgment.Thiswillshowtherequirementsimposedbythecourt;AND
Dismissal,probationrelease,courtdischarge.
4.EmploymentInformation
Fillinyouremploymentinformationforcurrentandpastemploymentforthepastfiveyears.(Ifyouhavenotaccounted
forfiveyearsofemploymentbelow,addadditional/previousemployersonaseparatepageandincludeallfieldsbelow.)
CurrentEmployer(s)
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
PreviousEmployer(s)
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
Wereyouterminatedordidyouresigninlieuoftermination?
Yes No
Ifyes,pleaseexplainornoteyourreasonforleaving: 
Employer:__________________________________________________________________________________________
Address:___________________________________________________________________________________________
StreetCityStateZip
PhoneNumber:_______________________Position/Title:_________________________________________________
StartDate:__________________________EndDate:_________________________
Supervisor’sName:_____________________________________Supervisor’sPhoneNumber:_____________________
Wereyouterminatedordidyouresigninlieuoftermination?
Yes No
Ifyes,pleaseexplainornoteyourreasonforleaving: 
5.DocumentRequirements
Checkofftheboxesbelowtoensureyouhaveprovidedalldocumentationrequiredtobesubmittedwiththis
questionnaire.
ADetailedWritten(orTyped)Statement.
ALLPolice,Sheriff,orLawEnforcementRecords.
ALLCourtDocuments.
5a)Ifnoformalcourtchargesresultedfromthearrestorcitation,youmuststillincludethepolicereport.However,inplace
ofthecourtrecordslistedabove,pleaseprovide:
Documentationorletterfromthepolicedepartmentorcourtstatingthatnochargeswerefiledorthat
prosecutionwasdeclined.
5b)Ifthearrest,citationorchargeoccurredseveralyearsagoandpoliceorcourtrecordshavebeenpurgedorarenolonger
available,adocumentonletterheadfromthepolicedepartmentandcourtstatingthatthefilesonyourcasenolonger
exist,willberequiredandacceptableifitincludesthefollowing:
Yourname,dateofbirth,socialsecuritynumber(usedbytheagencytoconductthesearch).
Thetypeofcharge(whatthearrestwasfor)andthedateandyearthearresttranspired.
Name/phonenumberofthepolicedepartmentorcourtcontactperson.
Iverifythattheaboveinformationprovidedbymeandansweredwithinthisquestionnaireistrue,completeandcorrect,
andIhavedisclosedeachofmyarrests,citationsandcharges,forfeloniesandmisdemeanors,includingincidentsthatdid
notultimatelyresultinconvictions.
__________________________________________________________ _________________________
SignatureDate
click to sign
signature
click to edit
ComplaintorSelf‐ReportProcess
http://azbn.gov/faqs/discipline‐complaints/submitting‐a‐complaint‐faqs/
1.Whathappenswiththecomplaint?
Whenacomplaintorself‐reportisreceivedbytheBoard,itisfirstreviewedtodeterminejurisdiction.IftheBoardhas
jurisdiction,aninvestigatorandacasenumberareassigned.Notificationlettersaresenttothecomplainantandtothe
subjectofthecomplaintandtheinvestigativeprocessbegins.Thesubjectofthecomplaint(“Respondent”)ismade
awareofthespecificallegationsandisrequiredtorespondinwriting.Theinvestigatorcollectsobjectiveinformation
fromanumberofsources,interviewsthecomplainant,witnesses,andRespondent.Theinformationiscompiledintoan
investigativereporttopresentataboardmeetingfortheBoards’reviewanddecision.Theboardmeetingisopento
thepublic.ThecomplainantandRespondentmaychoosetobepresentandmakeastatementtotheBoardbutneither
isrequiredtodoso.TheboardmeetingisnotahearingbutratherisforumfortheBoardtodetermine,baseduponthe
investigativefindings,ifprobableevidenceexistthatalicenseorcertificateholderhasviolatedtheNursePracticeAct.
2.Canthesubjectofthecomplaint(“Respondent”)obtainlegalrepresentation?
Atanystageoftheinvestigativeprocess,thesubjectofthecomplaint(“Respondent”)mayobtainindependentlegal
representation.
3.Howlongdoestheinvestigativeprocesstake?
SeveralfactorsweighintohowlonganinvestigationmaytakebeforethecaseispresentedtotheBoard.TheBoard
considerstheseverityoftherisktothepublicfirstandforemostandprioritizesaccordingly.Somecasearemuchmore
complexthanothersandtakelongertoprocess.Iftheallegationmeetsthecriteriaforcaseopening,boththe
complainantandRespondentreceivenotificationthataninvestigationisinprocessandprovidedwithcontact
informationfortheassignedinvestigator.Weencourageyoutostayincontactwiththeinvestigatorthroughoutthe
processtofacilitatetheinvestigation.
4.Canthelicense/certificateholderorapplicantworkwhiletheyareunderinvestigation?
Theabilitytoworkasanurse,LNAorCNAisunrestrictedduringtheinvestigationaslongasthelicenseorcertificate
remainsactive.However,applicantsarenotissuedalicense/certificateuntiltheconclusionoftheinvestigationand
thereforecannotworkuntilalicense/certificatehasbeenissued.
5.Whatcanthesubjectofthecomplaint(“Respondent”)orpeoplemakingthecomplaint(“Complainant”)dotoassist
intheinvestigativeprocess?
Ifyouarethesubjectofthecomplaint(“Respondent”):keeptheboardapprisedofanychangesinyouraddressand
phonenumber,andrespondpromptlytoanyrequestsforinformationordocuments.Youwillberequiredtosubmita
writtenresponsetothecomplaintandwillberequestedtomeetwiththeassignedinvestigatorforaninterviewandto
reviewinformationobtainedduringthecourseoftheinvestigation.Yourinputandparticipationisimportantin
understandingwhatoccurred.
Ifyouhavefiledacomplaint(“Complainant”):submitallwrittendocumentationregardingyourconcerns,observations
andimpressionsconcerningtheincident.ProvidingdetailedinformationattheonsetisimportantinassistingtheBoard
tounderstandriskofharmandinfacilitatingtheinvestigativeprocess.
6.WhathappenswhenthecaseispresentedtotheBoard?
Theboardmeetingisanopenpublicmeetingwhereinvestigativereportsrelatedtocomplaintsthathavebeenreceived
andinvestigatedbystaffarereviewedbytheBoardmemberstodetermine,baseduponevidenceinacase,whether
thereisprobableevidenceofaviolationoftheNursePracticeAct.Boardmemberswilldeliberateandmakeamotion,
statingwhatactionshouldoccur.
7.WhocanaddresstheBoardmembers?
Ifyouhavesubmittedacomplaint(“Complainant”)oryouhavehadacomplaintsubmittedagainstyourapplicationor
yourlicense/certificate(“Respondent”),youarewelcometoattendtheboardmeetingtohearthediscussionandBoard
decision.Theboardmeetingisnotahearingbutyoumaychoosetogiveaverbalpresentation(upto5minutes),
providinginformationyoufeelispertinentfortheBoardtoconsider.Youmayalsochoosetojustbeavailableto
respondtotheirquestions,oryoumaybepresentandnotspeakatall.Informationthatisrelevanttothecomplaint
andinvestigationshouldhavebeenprovidedtotheassignedinvestigatorinadvanceoftheboardmeeting.
8.WhatarethepossibleBoardmembersdecisionsoractions?
Boardactionsarecategorizedas:Dismissal,Non‐disciplinaryAction,DisciplinaryAction,andAdministrative
Violations.OncethecasehasbeenreviewedbytheBoardandtheBoardvotesfordiscipline,thelicensee/certificate
holder/applicantstatusisupdatedtoreflect"complaint‐outcomepending"oriffinal,thedisciplinaryactiontaken.
Dismissal Dismissal–EvidencedoesnotsupporttherehasbeenaviolationoftheNursePracticeAct.
Non‐Disciplinary LetterofConcern–AletterfromtheBoardexpressingconcernthatalicensee,certificateholderor
applicantmayhavebeenengageinquestionableconductthatisconsideredlowriskorharmtothe
public.AletterofconcernissuedbytheBoardisnon‐disciplineandisnotanappealableagency
action
DisciplinaryActions CivilPenalty–AmonetaryfineissuedbytheBoard,nottoexceed$1,000,givensinglyorin
combinationwithanydisciplinaryactionforaviolationoftheNursePracticeAct.
DecreeofCensure–ThisisanofficialdisciplinebytheBoardthattheindividual’sconductviolated
theNursePracticeActbutdoesnotrepresentacontinuedrisktothepatient/public.
Probation–Thisactionallowsthenursetocontinueworkingduringtheperiodofprobation
subjecttocompliancewiththetermsandconditions.Duringtheperiodofprobationthenurse
mustbesupervisedintheirpracticeandcompletecertainrequirementswhichareaimedat
rehabilitationoreducatingandremediatingthenurseinhis/herarea(s)ofpracticedeficit.For
example,anursewithasubstanceabuseissuemayberequiredtoenterandcompletetreatment,
attendAA/NAmeetings,abstainfromalcoholandotherdrugusealongwithother
requirements.Anursewholackssufficientknowledgeofmedicationsorsafeadministrationmay
berequiredtotakeapharmacologycourse,etc.
Suspension–Apersonwhohasbeensuspendedmaynotpracticeduringtheperiodof
suspension.Apersonwhohasbeensuspendedhastermsandconditionswhichmustbefulfilled
duringtheperiodofsuspensionandbeforebeingallowedtoresumepractice.Examplesofterms
andconditionsmayincludecompletingarefreshercourse,psychologicalorsubstanceabuse
treatmentinadditiontootherrequirements.Alicensee/certificateholderthathasbeen
suspendedoftenhasaperiodofprobationormonitoringfollowingsuccessfulcompletionofthe
termsofsuspension.
Revocation–Thisactionprohibitsthenurse/certificateholderfrompracticingforaminimumof
fiveyears,pursuanttoA.A.C.R4‐19‐404.Whenalicense/certificatehasbeenrevoked,the
applicantforre‐issuancemustprovidedetailedinformationtotheBoardthatthereasonfor
revocationnolongerexistsandthattheissuanceofalicense/certificatewouldnolongerthreaten
thepublichealthorsafety.A.A.C.R4‐19‐404orR4‐19‐815)Theindividualwhoselicense/certificate
hasbeenrevokedmaynotpracticeorotherwiseindicatetothepublicthattheyholda
license/certificate.
Denial–Aperson(applicant)whohasbeendeniedalicense/certificatemaynotpracticeandisnot
eligibletoreapplytotheBoardforaperiodoffiveyears.
VoluntarySurrender–AConsentAgreementhasbeensignedinwhichanAPRN,RN,LPN,LNA,
CNAhasvoluntarilysurrenderedtheirlicenseorcertificate.
Administrative
Violations
AdministrativePenalty–Apenalty/finegiventoalicenseeorcertificateholderwhohasworked
onanexpiredlicense/certificate,orfailedtonotifytheBoardofanaddresschangewithin30days.
ItisnotreportabletoNCSBNorothernationaldatacenters.
9.WhenistheBoarddecisionfinal?
Fordisciplinetobefinalandineffect,aRespondentmusteitherconsenttothedisciplineasvoteduponbytheBoardby
signinga“ConsentAgreement”orifnotsigned,theRespondenthashadanopportunityforahearing.Hearingsare
conductedattheOfficeofAdministrativeHearingsandthepersonconductingtheHearingisanAdministrativeLaw
Judge(ALJ).
Followingthehearingandbasedupontheevidencepresented,theALJsubmitsrecommended“FindingsofFact,
ConclusionsofLawandOrder”totheBoard.TranscriptsofthehearingarereviewedbytheBoardmemberspriorto
votingontheappropriatedisciplinaryactions(ifany)tobetaken.TheBoardhasfinalauthoritytodeterminediscipline
andcanadopt,modifyorrejecttheALJrecommendation.Ifdisciplineisdeterminedtobeappropriatebythemajority
oftheBoardMembers,a“BoardOrder”isissued.IftheRespondentdisagreeswiththeoutcome,arequestfor
rehearingmustbefiledwithin30daysofthemailingoftheBoard’sdecisionandOrder,otherwise,thematterisfinal.
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Form 607: a Stat ing of Nurs e (Arizona State Board of Nursing)

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Completed 27 January 2021

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