Louisiana State Board of Nursing
17373 Perkins Road Baton Rouge, LA 70810
Phone: (225) 755-7500
www.lsbn.state.la.us
Clinical Nursing Student Disclosure Form
This disclosure form is ONLY to be completed by clinical nursing students that have previously
been previously approved by LSBN and are currently enrolled in a clinical Nursing course.
Clinical Student Information (Print in Blue or Black Ink)
(Information different from original application will be updated at LSBN)
Name: __________________________________________________________________________
LSBN Student number or Social Security Number: ______________________________________
Address:_________________________________________________________________________
Street and number City/State/Zip Code
Phone: __________________DOB: ___________ Email Address: ___________________________
Name of Nursing Program Currently Enrolled: _____________________________________
Reason for Disclosure
Check the blank next to the reason(s) for this disclosure.
_________ I have been arrested, charged, arraigned, indicted, issued a summons or citation, or have
had a warrant issued for my arrest. (This does NOT include traffic violations such as
speeding or parking tickets.)
_________ My license to practice nursing or as another health care provider has been denied,
revoked, suspended, sanctioned, or otherwise restricted or limited. This includes
voluntary surrender of license and restrictions associated with participation in
confidential alternatives to disciplinary programs.
_________ I have been discharged from the military on ground(s) other than an honorable discharge.
_________ I have been diagnosed with / have / or have had a medical, physical, mental, emotional or
psychiatric condition that might affect my ability to safely practice as a Registered Nurse.
_________ I had / have a problem with, been diagnosed as dependent upon, or been treated for
mood-altering substances, drugs, or alcohol. I have been diagnosed as dependent
upon/addicted to or treated for dependence upon medications.
_______________________________________ __________________________
Student Signature Date
_______________________________________ ___________________________
Dean/Director Signature Date
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STU 04 Rev 6/24/14, 1/5/1, 1/22/16, 3/31/16. 7/25/16 PAD
Required Documentation
Disclosure of arrest, citation, summons, warrant, charges, indictment:
1. Student’s detailed statement regarding the incident including date, names of
arresting/citing agencies, and current status of any pending legal action.
2. CERTIFIED TRUE COPIES of the following:
- Arrest/investigative report(s), citation, summons, warrants, indictments
- All court minutes, judgments and sentencing, or court orders
- Pretrial Intervention program agreements and letters of completion of all requirements
- Release from probation, and other relevant records to show resolution of the case.
Disclosure of action taken against practice nursing or as another health care provider:
1. Student’s detailed statement regarding the circumstances that lead to the action, the
current status of the action, any other information relevant to the disclosure.
2. CERTIFIED TRUE COPIES of the following:
- Other board actions
- Letters of current standing of licensure
Disclosure of other than honorable military discharge:
1.
Student’s detailed statement regarding the circumstances that lead to the discharge and current
status of any pending charges/preceding(s).
2. CERTIFIED TRUE COPIES of the following:
- Military discharge documents
- Documentation of the underlying action(s) that resulted in discharge
Disclosure of medical / physical / mental / emotional / psychiatric condition:
1. Student’s detailed statement regarding the disclosed condition including the date that
the condition was diagnosed and what treatment has been sought for the condition,
and list all medications prescribed.
2. Have diagnosing and/or treating professional complete the Clinical Nursing Student Medical-Mental
Condition Diagnostician / Treating Provider Form and include any medical/treatment records relevant
to the disclosed condition.
Disclosure of dependence / addiction to mood-altering substances:
1. Student’s detailed statement including a history of the dependence including substances
used/abused, treatment, and current date of sobriety.
2. Enclose all substance abuse treatment records, documentation of sobriety, and letter(s) from any
licensed professionals that are providing treatment relative to your dependence/addiction
that can address your current status in recovery and ability to safely practice nursing.
This disclosure form is ONLY
to be completed by clinical nursing students that have
previously been approved by LSBN and are currently enrolled in a clinical Nursing
course. All others will not be reviewed or processed.
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STU 04 Rev 6/24/14, 1/5/1, 1/22/16, 3/31/16. 7/25/16 PAD