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Lsbn Instructions For App (Delgado Community College)

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LOUISIANA STATE BOARD OF NURSING
17373 PERKINS ROAD
BATON ROUGE, LOUISIANA 70810
PHONE: 225-755-7500
Education Department
Phone: 225-755-7522
Fax: 225-755-7580
E-mail: education@lsbn.state.la.us
INSTRUCTIONS FOR APPLYING FOR
APPROVAL TO ENROLL IN CLINICAL NURSING COURSES
(LAC 46: XLVII.3324.B.4.a)
• This application is for Permission to Enroll in Clinical Nursing Courses. Registration in
Louisiana is mandatory to enroll in clinical nursing courses at undergraduate nursing
education programs approved by the Louisiana State Board of Nursing.
• Students may not enroll in clinical nursing courses in Louisiana without approval from
the LSBN. (LAC 46: XLVII.3324)
• Please read all application instructions carefully before completing your application.
• By submitting the application for permission to enroll in clinical nursing courses, you
are attesting that you have read and understand the Louisiana Nurse Practice Act (NPA)
and Rules and Regulations that govern licensure in Louisiana. The NPA and the Rules
and Regulations may be accessed on our website at www.lsbn.state.la.us.
Fees
• All fees must be submitted through the Nurse Portal. All fees are non-refundable.
$50.00 for Application for Permission to Enroll in Clinical Nursing Courses
$38.00 for Criminal Background Check
Eligibility criteria for applicants for clinical nursing course include:
♣ Must be admitted and accepted to an approved nursing education program
♣Freedom from restriction of any form by any nursing or health regulatory board in
any state;
♣ No civil or criminal charges pending;
♣ No allegation of cause for denial of licensure;
♣ Submit application to the Board at least 60 days prior to date of enrollment in the
clinical nursing course;
Applicant MUST submit the following documents through Portal
♣ Application
♣ Supporting documents identified on application
Applicant MUST submit the following documents to Nursing Education Program
♣ Criminal Background Check packet
♣ 2 fingerprint cards
♣ Fingerprint Authorization forms
Nursing Education Program MUST submit the following documents through the
Mail
♣ List of applicants submitting applications on form supplied by LSBN
♣ Criminal Background Check packet for each student
♣ 2 fingerprint cards
♣ Fingerprint Authorization forms
Completion of Application
NOTE: Incomplete Applications cannot be processed
• All documents must be accurately completed. This application and all documents
submitted will be a permanent part of your record. Answer all questions honestly as the
Board may deny your application if you provide false information or if you fail to
provide relevant information.
• Please use your full legal name. Nicknames are not acceptable. If your birth certificate
name is significantly different from your current legal name (other than marriage), attach
a letter of explanation. Documentation may be required. If your name changes after the
forms are submitted, a notarized statement showing the change or marriage certificate
must be submitted to the Board’s office. (If you are using a hyphenated name, please
make sure to use it on all forms.)
•The applicant will be notified via the Nurse Portal when the application has been
approved or if additional information is needed. Check the Nurse Portal for status updates
and correspondence as well as the e-mail entered as the username for correspondence.
•Applicant is responsible for changing contact information in the Nurse Portal.
• Forms may be accessed through the Nurse Portal (Refer to previous instructions for
method of submission to LSBN. Please keep your originals for your files).
http://www.lsbn.state.la.us/Education/RNStudents.aspx
1. Clinical Diagnostician Form
2. Criminal Background Check Packet (original Signature Must be submitted)
•Incomplete Application (Packets will not be processed)
Applications will not be processed and will remain pending if:
- Application or CBC packet is missing information;
- Application is not approved by School of Nursing Designee;
- Failure to include ALL required documents for questions for which you
answered “yes” (LAC 46: XLVII.3324.B.4.a);
- Payment is not received (application $50.00, Criminal Background Check
$38.00).
• Failure to disclose criminal history as outlined on the application will result in delay in
processing application and may result in a fine or denial for Falsification of Applications
(LAC 46: XLVII.3324.C).
REVIEW LSBN RULES AND REGULATIONS (website) – LAC 46: XVLII.3331
Denial or Delay of Licensure, Reinstatement, or the Right to Practice Nursing as a
Student Nurse to determine eligibility for approval for clinical and licensure in Louisiana.
Criminal Background Check
APPLICANTS WHO HAVE SUBMITTED A CRIMINAL BACKGROUND CHECK
TO LSBN WITH A PREVIOUS APPLICATION FOR PERMISSION TO ENROLL IN
CLINICAL COURSES IN LOUISIANA ARE NOT REQUIRED TO SUBMIT A NEW
CRIMINAL BACKGROUND CHECK PACKET UNLESS DIRECTED BY LSBN
STAFF.
APPLICANTS WHO HAVE NEVER SUBMITTED A CRIMINAL BACKGROUND
CHECK PACKET TO LSBN MUST SUBMIT A COMPLETE PACKET
Instructions for submission of a criminal background check packet:
*Clinical students must submit the completed packet to their school of nursing.
1. Download the Licensure Exam Fingerprint Instructions and Authorization for
Criminal Background Check form from the LSBN website.
2. Each of the two (2) FBI cards need a separate and distinct set of your
fingerprints. If the agency utilizes an electronic scan system, request that they
scan your fingerprints and print the first FBI card, then scan your fingerprints
again and print the second FBI card.
3. The fee for the fingerprint process is $38.00 is paid through the Nurse Portal.
4. Submit original cards and authorization forms to school of nursing.
• LAC 46: XLVII.3330.J-K states:
J. 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.
K. 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.
Responses from LSBN
• The applicant will be notified via the Nurse Portal when the application has been
approved or if additional information is needed. Check the LSBN Nurse Portal
http://www.lsbn.state.la.us for status updates and correspondence as well as the email
entered as the username for correspondence.
• Notification will be sent if additional information is required or if the Education
department cannot approve and therefore, transfers file to Investigations.
• Failure to respond to the LSBN’s request by deadline on letter may result in inactivation
of application.
• Approval Status/Student Number is considered a license.
• Print verification of approval from website and submit to school of nursing.
Approved student responsibilities
• It is your responsibility to re-enter the LSBN Nurse Portal and update your file as
required: http://www.lsbn.state.la.us
• It is your responsibility to disclose through the complaint portal if you have a
subsequent incident, change answers to any eligibility questions, or change contact
information.
• It is your responsible to maintain user id and password for nurse portal access for
updates and completion of future licensure applications with LSBN.
Revised: 2/08, 6/11, 3/12, 2/15, 8/18
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 application. 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 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 their 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 try to arrive at the LSBN office by midday to allow sufficient
time for processing if using the ‘LiveScan’ CBC option. The nurse must be able to submit their application
(already completed & notarized) and fee(s) to LSBN staff when he/she arrives for ‘LiveScan’ fingerprinting.
2) Fees due LSBN for CBC:
$38.00 – Paid electronically with submission of your application through the Nurse Portal; and an additional
$10.00 – Payable to Louisiana State Board of Nursing (LSBN) if coming in person to the LSBN office to have
your hands scanned using the ‘LiveScan’ equipment. (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
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****
Fees for CBC (money order or bank cashier’s check required, payable to LSBN):
$38.00 – Payable to Louisiana State Board of Nursing (LSBN) if paper FBI fingerprint cards are submitted
- OR –
$48.00 – Payable to Louisiana State Board of Nursing (LSBN) if coming in person to the LSBN office to have your
hands scanned using the LiveScan equipment. (Licensed Registered Nurses only).
** Refer to your Application Instructions to see if the above CBC cost if already incorporated in the application fee total**
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
****PLEASE PRINT (except ‘Signature) – USE BLUE OR BLACK INK WHEN FILLING OUT THIS FORM ***
Louisiana State Board of Nursing Patricia A. Dufrene, Ph.D., RN
FACILITY OR AGENCY FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE
Cynthia York, DNP, CGRN
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 but Signature **
APPLICANTS 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}
APPLICANTS SIGNATURE: _____________________________________________________________
APPLICANTS 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
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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Lsbn Instructions For App (Delgado Community College)

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Completed 26 July 2020

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