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BOARD OF REGISTERED NURSING

PO Box 944210, Sacramento, CA 94244-2100

P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

GENERAL INSTRUCTIONS AND APPLICATION REQUIREMENTS FOR

PUBLIC HEALTH NURSE (PHN) CERTIFICATION

GENERAL INSTRUCTIONS

Pursuant to Section 2818 (a) of the Business and Professions Code the Legislature recognizes that public

health nursing is a service of crucial importance for the health, safety, and sanitation of the population in all of

California’s communities. These services currently include, but are not limited to:

♦ Control and prevention of communicable disease.

♦ Promotion of maternal, child, and adolescent health.

♦ Prevention of abuse and neglect of children, elders, and spouses.

♦ Outreach screening, case management, resource coordination and assessment, and delivery and

aluation of care for individuals, families, and communities

In addition, Section 2818 (c) states that no individual shall hold himself or herself out as a public health nurse

or use a title which includes the term “public health nurse” unless that individual is in possession of a valid

California public health nurse certificate issued pursuant to this article.

I. GENERAL APPLICATION REQUIREMENTS

Public Health certification eligibility requires the possession of an active California registered nurse (RN) license

(California Code of Regulations, Section 1491).

If you do not possess an active California RN license and have never applied for a California RN license, an Application

for California RN Licensure by Endorsement/Examination must also be submitted. If you have had a permanent California

RN license, you must either renew or reactivate the California RN license.

The Public Health Nurse Application fee is an earned fee; therefore, when an applicant is found ineligible the application

fee will not be refunded. Processing times for certification may vary, depending on the receipt of required documentation.

Processing a Public Health Nurse Certification application indicating prior disciplinary action(s

) and/or voluntary

surrender(s) may take longer. A pending application file 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 PHN

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.

II. NAME AND/OR ADDRESS CHANGES

California Code of Regulations, Section 1409.1 requires that you notify the Board of Registered Nursing of all names 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 along with legal

documentation of the name change to the Board. Examples of acceptable forms of legal documentation are birth

certificate, marriage certificate, divorce decree and/or court documents, social security card or passport. A copy of a

driver’s license is not acceptable.

(Rev 6/20)

GENERAL INSTRUCTIONS – (continued)

III.

U.S. SOCIAL SECURITY NUMBER, INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER &

TAX INFORMATION

Disclosure of your U.S. Social Security Number or Individual Taxpayer Identification Number 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 or Individual Taxpayer Identification Number. Your U.S. Social Security Number

or Individual Taxpayer Identification Number 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 where licensure is reciprocal with the requesting state. If you fail to disclose

your U.S. Social Security Number or Individual Taxpayer Identification Number, your application for initial or

renewal license/certification will not be processed. You will also be reported to the Franchise Tax Board, which

may assess a $100 penalty against you. Questions regarding the Franchise Tax Board should be directed to (800)

852-5711.

ALERT: Effective July 1, 2012, the Board of Registered Nursing is required to deny an application for licensure and to

suspend the license/certificate/registration of any applicant or licensee who has outstanding tax obligations due to the

Franchise Tax Board (FTB) or the State Board of Equalization (BOE) and appears on either the FTB or BOE's certified

lists of top 500 tax delinquencies over $100,000. (AB 1424, Perea, Chapter 455, Statutes of 2011).

IV. RE

PORTING PRIOR DISCIPLINE AGAINST LICENSES/CERTIFICATES

All disciplinary action against an applicant's public health nurse, registered nurse, practical nurse, vocational nurse or

other health care related license or certificate must be reported.

Failure to report prior convictions or disciplinary action is considered falsification of application and is

grounds for denial of licensure/certification or revocation of license/certificate.

When reporting prior disciplinary action, applicants are required to provide a full written explanation of:

circumstances surrounding the disciplinary action(s) and the date of or disciplinary action(s). For disciplinary

proceedings against any license as a RN or any health-care related license; include copies of state board

determinations/decisions, citations and letters of reprimand.

To make a determination in these cases, the Board 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 be limited to:

• Recent, dated letter from applicant describing the event and rehabilitative efforts or changes in life to prevent

future problems or occurrences.

• Recent and signed letters of reference on official letterhead from employers, nursing instructors, health

professionals, professional counselors, parole or probation officers, Support Group Facilitators or sponsors, 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.

• Submit copies of recent work evaluations.

• Proof of community work, schooling, self-improvement efforts.

(Rev 6/20)

GENERAL INSTRUCTIONS – (continued)

All of the above items should be mailed directly to the Board by the individual(s) or agency that is providing information

about the applicant. Have these items sent to the Board of Registered Nursing, Advanced Practice Unit – Public Health

Nurse Certification (PHN), P.O. Box 944210, Sacramento, CA 94244-2100.

It is the responsibility of the applicant to provide sufficient rehabilitation evidence on a timely basis so that a

certification determination can be made.

An applicant is also required to immediately report, in writing, to the Board any disciplinary action(s) which

occur between the date the application was filed and the date that a California Public Health certificate is

issued. Failure to report this information is grounds for denial of licensure or revocation of license/

certificate.

NOTE: The application must be completed and signed by the applicant under the penalty of perjury.

V. BOARD ADDRESS & WEB SITE INFORMATION

Mailing Address: Advanced Practice Unit – PHN Certification

Board of Registered Nursing

P.O. Box 944210

Sacramento, CA 94244-2100

Street Address for overnight or in-person delivery:

Advanced Practice Unit – PHN Certification

Board of Registered Nursing

1747 N. Market Blvd., Suite 150

Sacramento, CA 95834-1924

Web Site: www.rn.ca.gov

VI. CALIFORNIA NURSING PRACTICE ACT

California statutes and regulations pertaining to Registered Nurses/Public Health Nurses may be obtained by accessing

the Board of Registered Nursing web site at www.rn.ca.gov

(Rev 1/19)

APPLICATION REQUIREMENTS FOR

PUBLIC HEALTH NURSE (PHN) CERTIFICATION

METHOD A

Possession of a baccalaureate or entry-level master’s degree in nursing from a nursing school accredited by the National

League of Nursing (NLN) or the Commission on Collegiate Nursing Education (CCNE) which includes coursework in

public health nursing, including a minimum of 90 hours of supervised clinical experience in a public health setting(s).

Documentation submitted directly to the Board of Registered Nursing:

1. Completed Public Health Nurse (PHN) Certification and applicable fee.

2. R

equest for Transcript form completed by the baccalaureate, entry-level master’s or master’

ademic program. (Page

OTE: All out-of-state graduates must have the shaded verification section completed by the

academic program.)

3. Official transcripts for the completed baccalaureate program, entry-level master’s program

aster’s program submitted by the academic program

4. Verification of training in the detection, prevention, reporting requirements and treatment of child

neg

lect and abuse which shall be at least 7 hours in length and shall include but not limited t

evention techniques, early detection techniques, California reporting requirements

and

ntervention techniques completed in a baccalaureate or specialized program in nursing or

ourse approved for continuing education (CE) by the Board of Registered Nursing. The cours

ust include coverage of the California Reporting Law requirements per Section 11166.5 of t

California Penal Code.

(NOTE: California BSN graduates prior to 1981, must take the 7 hour child abuse/neglect

prevention training course approved by the Board of Registered Nursing.

5. Course descriptions for the completed baccalaureate program, entry-level master’s program

master’s program. The course descriptions must be for the period of time you attended the

program. (This does not apply to California graduates)

METHOD B

Possession of a baccalaureate or entry-level master’s degree in nursing from a nursing school which has not been NLN or

CCNE accredited which includes course work in public health nursing and includes a minimum of 90 hours of supervised

clinical experience in a public health setting(s).

Documentation submitted directly to the Board of Registered Nursing:

1. Completed Public Health Nurse (PHN) Certification and applicable fee.

2. R

equest for Transcript form completed by the baccalaureate, entry-level master’s or master’

ademic program. (Page

3. O

fficial transcripts for the completed baccalaureate program, entry-level master’s program

master’s program submitted by the academic program.

4. V

erification of training in the detection, prevention, reporting requirements and treatment of ch

ild

neg

lect and abuse which shall be at least 7 hours in length and shall include but not limited t

evention techniques, early detection techniques, California reporting requirements

and

ntervention techniques completed in a baccalaureate or specialized program in nursing or

course approved for continuing education (CE) by the Board of Registered Nursing. The course

must include coverage of the California Reporting Law requirements per Section 11166.5 of the

alifornia Penal Cod

(Rev 1/19)

APPLICATION REQUIREMENTS FOR

PUBLIC HEALTH NURSE (PHN) CERTIFICATION (CONT’D)

5. Course descriptions for the completed baccalaureate program, entry-level master’s program or

aster’s program. The course descriptions must be for the period of time you attended t

ogram

METHOD C

Possession of a baccalaureate degree in a field other than nursing and completion of a specialized public health nursing

program that includes a minimum of 90 hours of supervised clinical experience in a public health setting(s) associated

with a baccalaureate school of nursing accredited by NLN or CCNE. Work experience is not acceptable.

Documentation submitted directly to the Board of Registered Nursing:

1. Completed Public Health Nurse (PHN) Certification and applicable f

ee.

2. R

equest for Transcript form completed by the baccalaureate or master’s academic program

(

Page

3. O

fficial transcripts for the completed baccalaureate program or master’s program submitted b

he academic program

4. Verification of training in the detection, prevention, reporting requirements and treatment of child

neg

lect and abuse which shall be at least 7 hours in length and shall include but not limited t

evention techniques, early detection techniques, California reporting requirements

and

ntervention techniques completed in a baccalaureate or specialized program in nursing or

ourse approved for continuing education (CE) by the Board of Registered Nursing. The cours

ust include coverage of the California Reporting Law requirements per Section 11166.5 of t

California Penal Code.

5. C

ourse descriptions for the completed baccalaureate program or master’s program. The cours

des

criptions must be for the period of time you attended the program

PLEASE REFER QUESTIONS REGARDING THE PUBLIC HEALTH NURSE APPLICATION PROCESS

TO THE ADVANCED PRACTICE UNIT IN SACRAMENTO AT (916) 322-3350.

VII.

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.

(Rev 1/19)

BOARD OF REGISTERED NURSING

PO Box 944210, Sacramento, CA 94244-2100

P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

APPLICATION FOR PUBLIC HEALTH NURSE (PHN) CERTIFICATION

APPLICATION FEE - $300.00

MILITARY HONORABLE DISCHARGE - Check here if you served as an active duty

member of the Armed Forces of the United States and were honorably discharged.

PERSONAL DATA (PRINT OR TYPE)

LAST NAME:

FIRST NAME:

MIDDLE NAME:

ADDRESS: Number and Street

City

State

Country

Postal/Zip Code

HOME TELEPHONE NUMBER:

( )

ALTERNATE TELEPHONE NUMBER:

( )

E-MAIL ADDRESS:

DATE OF BIRTH:

(Month/Day/Year)

U.S. SOCIAL SECURITY NUMBER

or INDIVIDUAL TAXPAYER

IDENTIFICATION NUMBER:**

PREVIOUS NAMES: (Including Maiden)

MOTHER’S MAIDEN NAME:

(Last Name Only)

RN LICENSURE/PUBLIC HEALTH NURSE CERTIFICATION

California RN License Number: _____________________

Date Issued: _____________________

Expiration Date: _____________________

List ALL States Where You Hold/Held an RN License and

Status:

List ALL States Where You Hold/Held a Public Health Nurse

License/Certificate and Status:

PUBLIC HEALTH NURSE EDUCATION

TYPE OF PROGRAM:

___________________________________________________

Name of Public Health Nurse Academic Program

CERTIFICATE

BACCALAUREATE DEGREE

ENTRY LEVEL MASTERS DEGREE

MASTERS DEGREE/NURSING

___________________________________________________

City State Country

Entrance Date: __________________

Graduation/Completion Date: ___________________

CHILD ABUSE/NEGLECT PREVENTION TRAINING

___________________________________________________

CE Provider/School Name

Course Name: _______________________________

Course Number: _______________________________

Number of hours: __________________

(Rev 1/19)

(Questions on both sides of page)

_____________________________________________ ________________

NAME OF APPLICANT:

BACKGROUND INFORMATION

Have you applied for a Public Health Nurse certificate in California?

If yes:

Name on previous application: Date Submitted:

YES NO

Have you ever been issued a Public Health Nurse certificate in California?

If yes: STOP! DO NOT CONTINUE. Please contact the Board regarding whether you should reapply or file a petition

for reinstatement of your California Public Health Nurse certification.

YES NO

Have you ever had disciplinary proceedings against any license as a RN or any health-care related license or

certificate including revocation, suspension, probation, voluntary surrender, or any other proceeding in any state or

country? If yes, please provide a detailed written explanation, including the date and state or country where the

discipline occurred.

YES NO

Have you ever been denied an RN or any other health-care related license in any state/territory? If yes, please

provide a detailed written explanation, including the date and state or country where the discipline occurred.

YES NO

I understand that I am required to report immediately to the California Board of Registered Nursing disciplinary

action and/or voluntary

surrender against ANY health-care related license/certificate that occurs between the date of this application and the date that a California

registered nurse license and/or Public Health Nurse certificate is issued. I understand that failure to do so may result in denial of

this application or subsequent disciplinary action against my license/certificate.

I certify under penalty of perjury under the laws of the State of California, that all

Attach a recent 2”x2”

information provided in connection with this online application for license/certification is

passport type photograph.

true, correct and complete. Providing false information or omitting required information

is grounds for denial of licensure/certification or license/certificate revocation in

Please tape on all four sides.

California. I have read and understand the disclosure statements provided in the

instructions for this application. I hereby grant the Department of Consumer Affairs

Head and shoulders only

entity permission to verify any information contained in this application.

GNATURE OF APPLICANT DATE

** U.S. SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER DISCLOSURE STATEMENT

Disclosure of your U.S. Social Security Number or individual taxpayer identification number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA

(c)(2)(C) authorizes collection of your U.S. Social Security Number or individual taxpayer identification number. Your U.S. Social Security Number or individual taxpayer identification number will be

used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification

of licensure 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 or individual taxpayer identification number, your application for initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may

assess a $100 penalty against you.

(Rev 6/20)

BOARD OF REGISTERED NURSING

PO Box 944210, Sacramento, CA 94244-2100

P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

REQUEST FOR TRANSCRIPT

PUBLIC HEALTH NURSE CERTIFICATION

A. TO BE COMPLETED BY APPLICANT

Send this form to your baccalaureate, entry-level masters or master’s school of nursing. If you need to contact more than one school,

this form may be reproduced. Transcripts must include all completed course work and reflect the degree awarded and date conferred.

An official transcript must come directly from the school of nursing to the Board of Registered Nursing. Transcripts are not accepted

from applicants.

NAME: Last First Middle

Previous Names (Including Maiden):

ADDRESS: Street City State Zip Code

U.S. SOCIAL SECURITY NUMBER or

INDIVIDUAL TAXPAYER

IDENTIFICATION NUMBER:

BIRTHDATE:

Month Day Year

TELEPHONE NUMBER:

Home: ( )

Work: ( )

NAME OF BSN/ELM/MSN NURSING SCHOOL:

YEARS ATTENDED:

__________ to __________

LOCATION: City State (Country)

YEAR GRADUATED:

SIGNATURE OF APPLICANT: ______________________________________________ DATE: ______________________

B. TO BE COMPLETED BY THE SCHOOL OF NURSING

The above applicant has applied for Public Health Nurse Certification in California. Please supply the following

information and attach an official transcript.

ENTRANCE DATE:

DATE DEGREE AWARDED:

TYPE OF DEGREE AWARDED:

OUT-OF-STATE GRADUATES ONLY

Is this school NLN accredited?

Yes

If yes, when:

Is this school CCNE accredited?

Yes

If yes, when:

Was the school accredited at the time of applicant’s graduation?

Yes

SIGNATURE OF SCHOOL

OFFICIAL:

TELEPHONE: ( )

NAME & TITLE:

DATE:

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

BOARD OF REGISTERED NURSING

PO Box 944210, Sacramento, CA 94244-2100

P (916) 322-3350 F (916) 574-8637 | 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:

FAIL

URE 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 OR

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER 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.

IF YOU FAIL TO DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER

IDENTIFICATION NUMBER, 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

information:

POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND

REPORTING U.S. SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER

IDENTIFICATION NUMBER 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 03/13) 9

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 03/13) 10

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