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Louisiana-state-nursing-board-fall-application LOUISIANA STATE BOARD OF NURSING

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LOUISIANA STATE BOARD OF NURSING
17373 Perkins Road, Baton Rouge, Louisiana 70810
Telephone 225-755-7500 Fax: 225-755-7580
education@lsbn.state.la.us
APPLICATION FOR PERMISSION TO ENROLL IN
CLINICAL NURSING COURSES IN LOUISIANA
APPLICATION SUBMISSION
• For initial approval to enroll in a clinical nursing course, each student must submit this
application to his/her program head who will submit this form as appropriate to the
Louisiana State Board of Nursing (LSBN).
• Applications are due to LSBN no later than 60 days prior to enrollment into first clinical
course (LAC46:XVLII.3324) and are submitted to LSBN by School Program Head (via
postal service).
• The packet must include ALL of the following:
1. Completed Application signed by Program Head;
2. All of the supporting documentation listed under each question throughout the
application;
3. Authorization for Criminal Background Check (Please do not copy these two forms 2
sided);
4. FEES - A $50 application fee and Criminal Background Check fee of $40.75 (Total
$90.75 in the form of a money order payable to LSBN. (Fees are non-refundable); and
5. Two (2) distinct unique (10) ten-print fingerprint cards (Both fingerprint cards are to
be completed separately. Do not send 2 copies of one print.).
HELPFUL HITS
1. Applications will be processed for only one school. Please do not submit multiple applications.
2. DO NOT USE SCHOOL EMAIL ADDRESS: LSBN will send all correspondence to the mailing
and e-mail address on your application.
3. Read questions very carefully to avoid delays for non-disclosure.
4. Submit all required documents listed under each question with the application.
5. All documents must be original, true copies of narrative, arrest reports/citations, and court
documents regardless of disposition or expungement.
6. Provide official verification of other licenses with application.
7. Provide 2 distinct unique fingerprint cards and completed authorization forms. All changes in
name or contact information must be submitted to LSBN. Forms can be found on the LSBN website
(www.lsbn.state.la.us) on the Education page.
8. Future disclosures must submitted via the Disclosure form, which is found on the LSBN website
(www.lsbn.state.la.us)
RESUBMISSION OF APPLICATION PACKET
1. New application, documents and fees are required for the following:
a. Change of schools; or
b. As directed by School of Nursing and/or LSBN.
2. New Fingerprint cards are not required unless directed by LSBN Staff.
3. See instructions on previously disclosed section in Section II of application.
1
SECTION I. TO BE COMPLETED BY THE APPLICANT
PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK
1. N
ame:_____________________________________________________________________________________
First Middle Maiden/Last Name Married Name
2. P
ermanent Mailing Address: ****All correspondence will be sent to this address****
____
_________________________________________________________________________________________
Street
_____________________________________________________________________________________________
City State Zip Code
3. T
elephone No.:________________________________ Social Security No.:___________________________
Alternate/Cell Phone No.:____________________ Personal E-mail Address: ______________________
**** (Please do not use your school email address)
4. Date of Birth MM/DD/YYYY _______________________ Place of Birth: ____________________________
(city, state, country)
5. Name of Nursing Program (school name): _____________________________________________________
__
T
ype of program: Diploma_____________, ASN _____________, BSN ___________________
6. Other nursing programs to which admission was granted: ___________________________________________
(Include Schools(s) Semester/Quarter and Year)
7. Admission to nursing program (month and year requesting approval): (MM/YYYY)____________________
Date enrollment in Nursing Clinical course (MM/DD/YYYY)* __________________________________
*Application and supporting documents must be received 60 days prior to this date
Projected Date of Graduation: (MM/YYYY) _____________________
8
. O
ther licenses held (CNA, Respiratory Therapist, Paramedic, EMT, other *):____________________________
* I
nclude official verification of licensure statues from Licensing agency
.
9. A
re you a citizen of the United States? Yes ____ No_____ If no, give Alien Registration No.:_____________
10. Have you ever been licensed as a Practical Nurse (LPN/LVN) in Louisiana or any other state/jurisdiction?
YES_____ NO ______ If yes, what state(s)/jurisdiction(s)?______________________ when?______________
* Include official verification of licensure status from Licensing agency. (Louisiana- www.lsbpne.com
)
REVIEW THE FOLLOWING DOCUMENTS BEFORE PROCEEDING
1. INSTRUCTIONS for completion of application, Rules for Delay/Denial of Clinical enrollment,
Criminal Background Check Packet and Medical Diagnostician/ Treatment Provider Form, a
nd
D
isclosure Form for incidents occurring after approval can be found at
www.lsbn.state.la.us/Education/RNStudents
2. LSBN RULES AND REGULATIONS (website) – LAC46:XVLII.3331 Denial or Delay of
Licensure, Reinstatement, or the Right to Practice Nursing as a Student Nurse to determin
e
eli
gibility for approval for clinical and licensure in Louisiana.
3. LSBN ADVISORY STATEMENT (WEBSITE) regarding practicing while taking prescribed
me
dications are found on the LSBN website (www.lsbn.state.la.us
)
2
Delgado Community College
✔
08/2018
08/20/2018
11. Have you ever submitted an application for permission to enroll in clinical to LSBN?
YES________ NO ____If yes, when? (MM/YYYY) ___________________________________
RN School(s) approved by LSBN to attend
Program ________________________________ STU # (issued by LSBN) ______________
• Approval Status/Student Number is considered a licensure and can be verified at http://www.lsbn.state.la.us
under the Licensure tab using Name and Social Security.
Reason for resubmission (check all that apply):
_______ Changing School of Nursing
_______ Readmission after academic failure
_______ Previously delayed- providing new information
_______ Other - Please Explain: _________________________________________
SECTION II. TO BE COMPLETED BY THE APPLICANT
For all questions in this section:
• You must attach all requested documents listed for questions with “YES” answers. Applications will
not be processed until the items are received. Do not write responses directly on this application.
Please initial and date any errors made on this application.
• If you pr
eviously applied and checked “YES”/Disclosed and provided ALL of the listed documents
for the applicable question, then:
Check “yes” for appropriate question
Provide signed narrative as outlined under question and include statement regarding previous
disclosure and submission of information to LSBN.
If there is no new information/ please include statement stating this.
Yes__No__ 1. Have you ever been issued:
a citation or summons for,
has/have warrant(s) been issued against you related to,
have you been arrested, charged with, arraigned, indicted, convicted of,
pled guilty/”no contest”/nolo contendere/“best interest” or any similar
plea to,
been sentenced for any criminal offense, in Louisiana or other
jurisdiction?
NOTE: Even though an arrest or conviction has been, dismissed, deferred, or diverted,
and even if your civil rights have been restored, you must answer “YES” and mail
certified court documents of incident/arrest together with a signed letter of
explanation.
NOTE: No person whose record of arrest or conviction has been expunged [ordered
sealed, non-disclosed, and/or pardoned by a court in the applicant’s state or
jurisdiction] shall be required to disclose to any person that he [or she] was arrested or
convicted of the subject offense, or that the record of the arrest or conviction has
been expunged. La. C. Cr. P. Art. 973 (C). If the applicant does not know the
meaning of the terms set forth above, and/or has a question about the meaning of the
terms, then it is incumbent upon the applicant to seek legal counsel.
DWI arrest must be reported, regardless of final disposition.
Traffic violations such as speeding or parking tickets do not need
to be reported.
3
If yes, then you must:
o Provide your personal statement
of incidents and include:
o date of any/all citations;
o summons, warrants, arrests, charges, arraignments indictments,
convictions, pleas, sentence;
o the name of parish/county in which arrests, etc., occurred;
o the names of arresting agencies, the violation(s) listed;
o the final disposition of any/all criminal matters; and
o current status, if no final disposition.
o Enclose:
o certified true copies of any/all arrest report(s), etc., occurrence narrative/
supplemental reports;
o certified true copies of any/all court minute entries and court judgements/
orders and completion;
o copies of probation/DA diversion or Pretrial Intervention programs, and
documentation reflecting completion), etc.; and
o any/all other relevant records.
*
No faxed arrest records or court documents.
*** REVIEW LSBN RULES AND REGULATIONS -- LAC46:XVLII.3331
Denial or Delay of Licensure, Reinstatement, or the Right to Practice Nursing as a Student Nurse
(see LSBN website: www.lsbn.state.la.us)
Yes__ No__ 2. Have you ever had a license to practice nursing or as another health care
provider denied, revoked, suspended, sanctioned, or otherwise restricted or
limited, including voluntary surrender of license—including restrictions
associated with participation in confidential alternatives to disciplinary
programs?
Have you had disciplinary action pending by a licensing board—other than by
Louisiana State Board of Nursing—in any state or jurisdiction?
If yes, then you must:
o Provide your personal statement to include date of and description of any/all
actions by other licensing boards in Louisiana and in other states or jurisdictions
(beside the Louisiana State Board of Nursing), including names of other boards
at issue, status of any/all disciplinary matters with other boards,
o Enclose
certified true copies of any/all other board actions by other licensing
boards, along with any/all related and/or subsequent actions
Yes__No__ 3. Have you ever been discharged from the military on ground(s) other than an
honorable discharge?
If yes, then you must:
4
o Provide your personal statement to include the other-than-honorable discharge,
with date(s) of incident(s) involved, detailed description of grounds for discharge,
along with description of the surrounding circumstance and any/all other relevant
information.
o Enclose
photocopies of any/all military discharge documents, including any/all
documentation of the underlying action(s) that resulted in discharge, with any/all
other related records.
Yes__No__ 4 . Have you ever been diagnosed with, do you have, or have you had a medical,
physical, mental, emotional or psychiatric condition that might affect your
ability to safely practice as a Registered Nurse?
If yes, then you must:
o Provide your personal statement with date(s) of incident(s) involved, detailed
description of the condition(s) at issue, diagnoses, treatment received so far,
treatment planned or prescribed, information regarding the current status of your
condition(s), date, name and location of any/all treating facility(ies) and/or
treating caregiver(s), number of times in treatment, currently-prescribed
medication(s), and any/all other relevant information. Include in your statement if
you are going to apply for Social Security or insurance disability
o Enclose
o Completed Diagnostician /Treatment Provider form
http://www.lsbn.state.la.us/Portals/1/Documents/Forms/DiagnosticianForm.pdf
o photocopies of any/all discharge summaries, relevant medical records
and/or treatment record, written statement(s) sent directly from treating
physician(s) addressing current ability to safely practice nursing, along
with any/all related records.
Yes__No__ 5. Have you ever had a problem with, been diagnosed as dependent upon, or been
treated for mood-altering substances, drugs or alcohol?
Have you been diagnosed as dependent upon/addicted to, or been treated for,
dependence upon medications?
If yes, then you must:
Provide your personal statement to include date(s) of incident(s) involved,
detailed description of the condition(s) at issue, diagnoses, treatment received
so far, treatment planned or prescribed, information regarding the current
status of your condition(s), date, name and location of any/all treating
facility(ies) and/or treating caregiver(s), number of times in treatment,
currently-prescribed medication(s), and any/all other relevant information.
Include in your statement if you are going to apply for Social Security or
insurance disability.
5
Enclose photocopies of any/all discharge summaries, relevant medical
records and/or treatment record, written statement(s) sent directly from
treating physician(s) addressing current ability to safely practice nursing,
SECTION III. SUMMARY INSTRUCTIONS
• Refer to page 1 and instruction sheet found on LSBN website for complete instructions.
• If you answered “yes” to any questions in Section II, the requested documentation must
be submitted to your school of nursing along with your clinical application packet. Any
subsequent incident(s) must be immediately submitted in writing via this application to
the Louisiana State Board of Nursing.
• Failure to disclose or to correctly answer any questions in Section II may result in
disciplinary action. LAC46:XVLII.3324 Permission to Enroll or Progress in
Undergraduate Clinical Nursing Courses
• All applications and supporting documentation are requested no later than sixty (60) days
prior to enrolling in a clinical nursing course. Applications will not be processed until all
supporting documentation required has been received.
• Refer to LSBN website ( www.lsbn.state.la.us/Education/RNStudents) for the
following:
1. LSBN Advisory statement regarding practicing while taking narcotics
2. Rules regarding Delay/Denial of Clinical Course Enrollment
3. Application Instruction Sheet
4. Authorization for Criminal Background Check Forms
5. Change of Address Form
6. Diagnostician/Treatment Provider Form
7. Disclosure Form
SECTION IV . REPORTING OF CHANGES
SUBSEQUENT ARRESTS, CONVICTIONS OR IMPAIRMENT
If a student is admitted to the clinical sequence of the program, any subsequent changes in name
or contact information shall be immediately reported in writing to the LSBN using the Change of
Address form found on the website
If a student is admitted to the clinical sequence of the program, any subsequent action, arrest,
criminal charge or conviction or impairment shall be immediately reported in writing to the
LSBN and the program head.
6
SECTION V. Applicant Authorization
I HEREBY AUTHORIZE the Louisiana State Board of Nursing to release information to my
nursing program from my criminal history record as provided by the Louisiana Bureau of
Criminal Identification and information of the Office of State Police within the Department of
Public Safety and Corrections and from the Federal Bureau of Investigations.
Further, I certify that I am the person referred to in this application for permission to enroll in
clinical nursing course, that the statements herein contained are true in every respect; that I have
read and understand this affidavit. Falsification of any information accompanying or contained
on this application will result in disciplinary action by the Board, including denial of licensure.
__________________________________
Name of applicant (please print)
__________________________________________ ___________________________
Signature of Applicant Date Name of Nursing Program
SECTION VI. PROGRAM HEAD
_________________________________________________ ___________________________
Signature of Program Head Date
Mail all documents to:
Louisiana State Board of Nursing
17373 Perkins Road
Baton Rouge, LA 70810
All applications and supporting documentation are requested no later than sixty (60) days prior to enrolling
in a clinical nursing course.
STU 02
Rev. 08/01/12, 2/5/14, 4/28/14, 6/24/14, 10/1/2014, 1/5/15, 1/22/16, 7/25/16 PAD
OFFICE USE ONLY:
Received Date______________________ Clinical Start Date___________________
Approved BY (initial)________________ Approval Date______________________
Student Number____________________
7
Delgado Community College
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Louisiana-state-nursing-board-fall-application LOUISIANA STATE BOARD OF NURSING

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