Fillable Louisiana State Board of Nursing (Delgado Community College)

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Louisiana State Board of Nursing (Delgado Community College)

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Revised: 2/08, 6/11, 3/12, 2/15, 8/18, 11/18, 12/18
Louisiana State Board of Nursing
17373 Perkins Road, Baton Rouge, LA 70810
Telephone: (225) 755-7500
www.lsbn.state.la.us
FINGERPRINT INSTRUCTIONS FOR CRIMINAL BACKGROUND CHECK (CBC)
1) Authorization Forms: Complete, sign and date both of the following CBC authorization forms and submit to LSBN
together with the appropriate licensure application (if applicable), fees, and two (2) fingerprint FBI cards
:
* CBC1a:
Authorization for Criminal Background Check – Page I
* CBC1b: Authorization for Criminal Background Check – Page II
*Students submit completed cards to the office of your program head.
Fingerprinting: Contact your campus security (if you are a student) or state or local police/sheriff’s office to inquire about
their procedures, fees and locations for fingerprinting services. You must be fingerprinted by a law enforcement official onto
two (2) official Federal Bureau of Investigation (FBI) fingerprint cards.
If your local law enforcement office does not have
blank FBI cards, print paper cards to bring to the law enforcement office for fingerprinting at https://www.fbi.gov/file-
repository/standard-fingerprint-form-fd-258-1.pdf/view. If providing the CBC fingerprints cards & authorization sheets
to apply for initial licensure (including out of state exam applicants) or reinstatement in Louisiana, they must accompany a copy
of your receipt after applying for licensure online through the Nurse Portal: https://lsbn.boardsofnursing.org/.
Each of the two (2) FBI cards need a separate and distinct set of your fingerprints. If the law enforcement
agency utilizes an electronic scan system (‘LiveScan’), request they scan both hands for your fingerprints and
print the first (1
st
) FBI card, then scan your hands again to print your fingerprints on the second (2
nd
) FBI card.
The following suggestions may improve the quality of your fingerprints to ensure LSBN receives the results of
your CBC promptly:
Hands must be clean and dry. Wash your hands vigorously with warm water and dry thoroughly immediately
prior to being fingerprinted.
If hands are very dry or cracked, wash hands and apply a touch of moisturizer onto fingertips, removing any
excess lotion with paper towel prior to being fingerprinted. This may help raise the ridges for printing.
L.A.C.46:XLVII.3330 J-K states:
▪
If the fingerprints are returned from the Department of Public Safety as inadequate or unreadable, the
applicant, or licensee must submit a second set of fingerprints and fees, if applicable, for submission to the
Department of Public Safety.
▪ If the applicant or licensee fails to submit necessary information, fees, and/ or fingerprints, the applicant or
licensee may be denied licensure on the basis of an incomplete application or, if licensed, denied renewal,
until such time as the applicant or licensee submits the applicable documents and fee.
View both FBI cards before you leave the facility where you’re being fingerprinted. If any of the fingerprints are
outside the boxes, appear too light, too dark, or obviously smudged, have the technician prepare an extra set of
cards and submit both sets (all four cards) along with your forms. Protect both FBI cards from smudges. Do
not fold or staple. Do not submit 2 copies of the same prints.
All fingerprint cards must be signed by the applicant/nurse with all sections filled out completely with the
exception of the “employer and address” section.
Individuals who are already licensed Registered Nurses may opt to have fingerprints scanned in person at the
LSBN office (‘LiveScan’) by board staff instead of submitting paper FBI cards. ‘LiveScan’ fingerprinting must
be completed before 3:00 pm central standard time (CST). The LSBN office opens at 8:30 am (CST) but closed
for all state and federal holidays. Please arrive at the LSBN office by midday to allow sufficient time for
processing if using the ‘LiveScan’ CBC option. The nurse must have submitted the completed application online
through the Louisiana Nurse Portal prior to arriving for ‘LiveScan’ fingerprinting.
2) Fees due LSBN for CBC:
$39.25 – Paid electronically with submission of your application through the Nurse Portal; and an additional
$10.00 – Payable to Louisiana State Board of Nursing (LSBN) only if coming in person to the LSBN office for
the ‘LiveScan’ service. (Available to Licensed Registered Nurses only).
The additional fee for LiveScan must be paid by Money Order or Bank Cashier’s Check payable to LSBN
NOTE: If you are submitting to a CBC because you are applying for licensure or permission to enroll in clinical
nursing courses, please read the application instructions carefully regarding payment of fees. Some application
instructions will provide a ‘total fee’ to submit along with the application which may include the CBC fee noted above.
***Criminal history records check is authorized under the Nurse Practice Act, Louisiana Revised Statutes 37:920.1
Revised: 2/08, 6/11, 3/12, 2/15, 8/18, 11/18, 12/18
Authorization for Criminal Background Check (CBC) – Page I
**FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY**
****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION****
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
****PLEASE PRINT (except Signature) – USE BLUE OR BLACK INK WHEN FILLING OUT THIS FORM ***
Criminal history records check is authorized under the Nurse Practice Act, Louisiana Revised Statutes 37:920.1.
See instructions for submission of fees.
Louisiana State Board of Nursing Patricia A. Dufrene, PhD, RN
FACILITY OR AGENCY FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE
Cynthia York, DNP, RN, CGRN, FRE
FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE
17373 Perkins Road
MAILING ADDRESS SIGNATURE OF LSBN AUTHORIZED REPRESENTATIVE
Baton Rouge, LA 70810 (225) 755-7500
CITY STATE ZIP CODE FACILITY OR AGENCY PHONE NUMBER
Request For: (pick one only)
□ ALCOHOL AND BEVERAGE COMMISSION
□ ALCOHOL BEVERAGE OUTLET
□ CASA
□ CONCEALED HANDGUNS
□ CRIMINAL JUSTICE EMPLOYEE
□ DAYCARE
□ DENTISTRY BOARD
□ DEPARTMENT OF LABOR
□ DEPARTMENT OF PUBLIC SAFETY
□ EMPLOYERS
□ FIREFIGHTERS
□ GAMING
□ HEALTH CARE PROVIDER
□ IMMIGRATION
□ JUVENILE DETENTION CENTER
□ DEPARTMENT OF INSURANCE
□ MANUFACTURED HOUSING
□ MEDICAL EXAMINERS
□ OCS FOSTER/ADOPTIVE
□ OCS PERSONNEL
□ OFFICE OF FINANCIAL INSTITUTIONS
□ OFFICE OF PUBLIC HEALTH
□ PHARMACY BOARD
□ POSTSECONDARY EDUCATION
□ PRACTICAL NURSING
□ PRIVATE ADOPTION
□ PRIVATE INVESTIGATORS
□ PRIVATE SECURITY
□ PUBLIC HOUSING
□ PUBLIC TAG AGENT
REGISTERED NURSING
□ RELIGIOUS ACTIVISTS
□ RIVERBOAT PILOTS
□ SCHOOL
□ SENATE AND GOVERNMENTAL AFFAIRS
□ TAXI DRIVERS
□ USED MOTOR VEHICLE COMMISSION
□ VOLUNTEERS WITH YOUTH SERVING
ORGANIZATIONS
** Please print all except Signature **
APPLICANT NAME: __________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME (if different)
{Provide any and all ‘other’ Last Names held which are not listed above in the bottom margin of this page}
APPLICANT SIGNATURE: _____________________________________________________________
APPLICANT SOCIAL SECURITY # _ _ _ - _ _ - _ _ _ _ DATE OF BIRTH: _ _ / _ _ / _ _
DRIVERS LICENSE #:________________________& STATE _______ RACE _____ SEX ____
POSITION OR LICENSE APPLIED FOR
____________________________________________________
AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION
By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information
maintained in their files, other states’ files, FBI and/or international files (if applicable) which may confirm or deny my
eligibility with the facility or agency named above.
FORM NBR: CBC – 1a
RN
Revised: 2/08, 6/11, 3/12, 2/15, 8/18, 11/18
Authorization for Criminal Background Check (CBC) – Page II
APPLICANT PROCESSING-DISCLOSURE
BUREAU OF CRIMINAL IDENTIFICATION AND
INFORMATION
P.O. BOX 66613 (MAIL SLIP A-6)
LSPAPPR/R8.03
LOUISIANA STATE BOARD OF NURSING NOTICE:
AGENCY PLEASE PRINT OR TYPE INFORMATION,
EXCLUDING ADMINISTRATORS OR
AUTHORIZED PERSON SIGNATURE.
INCOMPLETE FORMS WILL NOT BE
PROCESSED.
17373 Perkins Road
MAILING ADDRESS
Baton Rouge LA 70810
CITY STATE ZIP CODE
Provide/print the following information below:
/ / /
APPLICANT’S FULL NAME (print) DATE OF BIRTH RACE SEX
SOCIAL SECURITY NUMBER
ALL INFORMATION RELEASED MUST REMAIN STRICTLY CONFIDENTIAL AND ONLY
THOSE AUTHORIZED BY LAW TO RECEIVE THIS INFORMATION MAY SUBMIT A REQUEST.
DO NOT WRITE BELOW THIS LINE: (FOR BUREAU OF CRIMINAL IDENTIFICATION AND INFORMATION USE ONLY
NOTICE: The response to your request for a criminal history check is based on a review of the State of Louisiana’s
criminal history records database as is available at the time of request. This does not preclude the possible existence of
conviction information not available in our database.
CRIMINAL HISTORY DETERMINATION:
RAPSHEET ATTACHED
RESPONSE BELOW
FORM NBR: CBC – 1b
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Completed 17 September 2020

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