Fillable REINSTATEMENT QUESTIONNAIRE If reason involved criminal conduct then (Arizona State Board of Nursing)

Fill Online, Printable, Fillable, Blank REINSTATEMENT QUESTIONNAIRE If reason involved criminal conduct then (Arizona State Board of Nursing) Form

Use Fill to complete blank online ARIZONA STATE BOARD OF NURSING (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

REINSTATEMENT QUESTIONNAIRE If reason involved criminal conduct then (Arizona State Board of Nursing)

On average this form takes 23 minutes to complete

The REINSTATEMENT QUESTIONNAIRE If reason involved criminal conduct then (Arizona State Board of Nursing) form is 5 pages long and contains:

  • 1 signature
  • 14 check-boxes
  • 81 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arizona State Board of Nursing

BROWSE ARIZONA STATE BOARD OF NURSING (AZ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
REINSTATEMENT QUESTIONNAIRE
NAME:
ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NUMBER: LICENSE NUMBER:
1. Briefly describe the circumstances leading to the surrender/revocation of your nursing license/certificate:
2.
Briefly describe what actions you have taken since the surrender/revocation of your license/certificate that would
ensure the board that these circumstances would not occur again: (Please attach any supporting documents that
you have)
3. Ha
s any other state taken action on your license/certificate as a result of the surrender/revocation by the Arizona
State Board of Nursing? If yes, describe circumstances.
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
ARREST/CHARGE/CITATION QUESTIONNAIRE
Instructions:
• A completed questionnaire MUST BE submitted for EACH arrest, charge, or citation you have ever received, regardless of age or
outcome (excluding civil traffic. DUIs, Reckless Driving, or Hit and Run incidents are not considered civil traffic). This means
incidents must be disclosed even if they were ultimately dismissed.
• Make as many copies of the questionnaire as you need in order to submit a separate questionnaire per incident.
• Please print neatly or type. Read each question carefully and answer every question. “See attached” is not an acceptable answer.
• Complete and submit ALL pages of the questionnaire, sign and date the last page, and attach the required police and court
records as well as your detailed written statement. Processing of your case will be delayed and additional questionnaires will be
sent if this required information is not submitted with each questionnaire and for every arrest, charge, or citation, regardless of
age or outcome. Failure to provide the required documents may be considered failure to cooperate with the Board investigation
and may constitute a violation of the Nurse Practice Act.
1. Demographic Information:
Full Name: __________________________________________________________________________________
First Middle Last
All Other/Former Names Used or Aliases (maiden, prior married names): ________________________________
___________________________________________________________________________________________
Social Security Number: _________________________ Date of Birth: __________________________________
Address: ____________________________________________________________________________________
Street City State Zip
Home Phone Number: __________________________ Cell/Mobile Number: _____________________________
2. Arrest/Charge/Citation Information:
Fill in the following information regarding the agency which arrested or cited you.
Name of law enforcement agency or sheriff office: ____________________________________________
Address of agency: _____________________________________________________________________
Street City State Zip
Date arrested/charged/cited: ______________________
For what offense(s) were you arrested, charged or cited? _____________________________________________
Was the arrest/charge/citation for: misdemeanor felony
I have requested from this law enforcement agency and am submitting with this questionnaire, as applicable, ALL required
police records listed below:
• Arrest/booking report, complaint, citation/ticket if applicable AND
• Officer narrative, arrest/incident department report. The narrative explains why the officer made contact with you
and what occurred during that contact AND
• All supplements or additions to the report, including results of testing, additional information, etc.
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
I am submitting with this questionnaire my detailed written (or typed) statement regarding the circumstances surrounding
this arrest, charge or citation.
When submitting a written explanation, be sure to be as specific as possible and address the “who, what, when, where, why and
how” of the circumstances regarding the incident. This is your opportunity to tell the Board what happened in your own words.
Failure to provide a detailed statement regarding each incident is a violation of the Nurse Practice Act.
3. Court Information:
Fill in the following information regarding the court where your case was heard or where your charges were submitted, if
applicable.
Name of Court: ________________________________________________________________________
Address of Court: ______________________________________________________________________
Street City State Zip
Of what offense(s) were you convicted?___________________________________________________________
Date of conviction: ______________________
Was the conviction: misdemeanor felony undesignated
Did you plead: guilty nolo contendere no contest
What was the sentence? (Include all fines, courses, counseling or group sessions, restitution, probation/parole, community
service, etc)
I
f the conviction was for a felony or undesignated offense, what was the date of completion of all probation requirements,
including payment of court fines and restitution (You must include proof of completion of probation/court
requirements/payment in full)? _____________________
Has there been any change in the designation of your conviction since the original sentencing (Examples: reduced to a
misdemeanor, set aside, dismissed, expunged, deferred)?
No Yes
If yes, what was the change? _____________________________________________________________
Are you currently on probation or parole? No Yes
If yes, when is your anticipated probation or parole end/discharge date? __________________________
Name of your probation/parole officer (PO): __________________________
Probation/parole officer phone number: _________________________
Were you ever found in violation of your probation or was a warrant ever issued? No Yes
If so, describe the circumstances of the violation:
_______
______________________________________________________________________________
Was your sentence modified as a result of your probation violation? No Yes
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
Explain: ______________________________________________________________________________
I have requested from this court and am submitting with this questionnaire, as applicable, ALL required court records listed
below:
• Notice of charges, complaint, indictment. This will show the Board what you were originally charged with; AND
• Pre-sentence screening, report or referral, pre-sentence report AND
• Plea agreement/s if applicable AND
• Sentencing, probation order/judgment. This will show the requirements imposed by the court AND
• Dismissal, probation release, court discharge.
4. Employment Information
Fill in your employment information for current and past employment for the past five years. (If you have not accounted for five
years of employment below, add additional/previous employers on a separate page and include all fields below.)
Current Employer(s)
Employer: __________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Phone Number: _______________________ Position/Title: _________________________________________________
Start Date: __________________________ End Date: _________________________
Supervisor’s Name: _____________________________________ Supervisor’s Phone Number: _____________________
Employer: __________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Phone Number: _______________________ Position/Title: _________________________________________________
Start Date: __________________________ End Date: _________________________
Supervisor’s Name: _____________________________________ Supervisor’s Phone Number: _____________________
Previous Employer(s)
Employer: __________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Phone Number: _______________________ Position/Title: _________________________________________________
Start Date: __________________________ End Date: _________________________
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
Supervisor’s Name: _____________________________________ Supervisor’s Phone Number: _____________________
Were you terminated or did you resign in lieu of termination? Yes No
If yes, please explain or note your reason for leaving:
Employer: __________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Phone Number: _______________________ Position/Title: _________________________________________________
Start Date: __________________________ End Date: _________________________
Supervisor’s Name: _____________________________________ Supervisor’s Phone Number: _____________________
Were you terminated or did you resign in lieu of termination? Yes No
If yes, please explain or note your reason for leaving:
5. Document Requirements
Check off the boxes below to ensure you have provided all documentation required to be submitted with this questionnaire.
A Detailed Written (or Typed) Statement.
ALL Police, Sheriff, or Law Enforcement Records.
ALL Court Documents.
5a) If no formal court charges resulted from the arrest or citation, you must still include the police report. However, in place of the
court records listed above, please provide:
• Documentation or letter from the police department or court stating that no charges were filed or that prosecution
was declined.
5b) If the arrest, citation or charge occurred several years ago and police or court records have been purged or are no longer
available, a document on letterhead from the police department and court stating
that the files on your case no longer exist, will
be required and acceptable if it includes the following:
• Your name, date of birth, social security number (used by the agency to conduct the search).
• The type of charge (what the arrest was for) and the date and year the arrest transpired.
• Name/phone number of the police department or court contact person.
I verify that the above information provided by me and answered within this questionnaire is true, complete and correct, and I
have disclosed each of my arrests, citations and charges, for felonies and misdemeanors,
including incidents that did not ultimately
result in convictions.
__________________________________________________________ _________________________
Signature Date
click to sign
signature
click to edit
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
Complaint or Self-Report Process
http://azbn.gov/faqs/discipline-complaints/submitting-a-complaint-faqs/
1. What happens with the complaint?
When a complaint or self-report is received by the Board, it is first reviewed to determine jurisdiction. If the Board has
jurisdiction, an investigator and a case number are assigned. Notification letters are sent to the complainant and to the
subject of the complaint and the investigative process begins. The subject of the complaint (“Respondent”) is made
aware of the specific allegations and is required to respond in writing. The investigator collects objective information
from a number of sources, interviews the complainant, witnesses, and Respondent. The information is compiled into an
investigative report to present at a board meeting for the Boards’ review and decision. The board meeting is open to
the public. The complainant and Respondent may choose to be present and make a statement to the Board but neither
is required to do so. The board meeting is not a hearing but rather is forum for the Board to determine, based upon the
investigative findings, if probable evidence exist that a license or certificate holder has violated the Nurse Practice Act.
2. Can the subject of the complaint (“Respondent”) obtain legal representation?
At any stage of the investigative process, the subject of the complaint (“Respondent”) may obtain independent legal
representation.
3. How long does the investigative process take?
Several factors weigh into how long an investigation may take before the case is presented to the Board. The Board
considers the severity of the risk to the public first and foremost and prioritizes accordingly. Some case are much more
complex than others and take longer to process. If the allegation meets the criteria for case opening, both the
complainant and Respondent receive notification that an investigation is in process and provided with contact
information for the assigned investigator. We encourage you to stay in contact with the investigator throughout the
process to facilitate the investigation.
4. Can the license/certificate holder or applicant work while they are under investigation?
The ability to work as a nurse, LNA or CNA is unrestricted during the investigation as long as the license or certificate
remains active. However, applicants are not issued a license/certificate until the conclusion of the investigation and
therefore cannot work until a license/certificate has been issued.
5. What can the subject of the complaint (“Respondent”) or people making the complaint (“Complainant”) do to assist
in the investigative process?
If you are the subject of the complaint (“Respondent”): keep the board apprised of any changes in your address and
phone number, and respond promptly to any requests for information or documents. You will be required to submit a
written response to the complaint and will be requested to meet with the assigned investigator for an interview and to
review information obtained during the course of the investigation. Your input and participation is important in
understanding what occurred.
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
If you have filed a complaint (“Complainant”): submit all written documentation regarding your concerns, observations
and impressions concerning the incident. Providing detailed information at the onset is important in assisting the Board
to understand risk of harm and in facilitating the investigative process.
6. What happens when the case is presented to the Board?
The board meeting is an open public meeting where investigative reports related to complaints that have been received
and investigated by staff are reviewed by the Board members to determine, based upon evidence in a case, whether
there is probable evidence of a violation of the Nurse Practice Act. Board members will deliberate and make a motion,
stating what action should occur.
7. Who can address the Board members?
If you have submitted a complaint (“Complainant”) or you have had a complaint submitted against your application or
your license/certificate (“Respondent”), you are welcome to attend the board meeting to hear the discussion and Board
decision. The board meeting is not a hearing but you may choose to give a verbal presentation (up to 5 minutes),
providing information you feel is pertinent for the Board to consider. You may also choose to just be available to
respond to their questions, or you may be present and not speak at all. Information that is relevant to the complaint
and investigation should have been provided to the assigned investigator in advance of the board meeting.
8. What are the possible Board members decisions or actions?
Board actions are categorized as: Dismissal, Non-disciplinary Action, Disciplinary Action, and Administrative Violations.
Once the case has been reviewed by the Board and the Board votes for discipline, the licensee/certificate
holder/applicant status is updated to reflect "complaint-outcome pending" or if final, the disciplinary action taken.
Dismissal Dismissal – Evidence does not support there has been a violation of the Nurse Practice Act.
Non-Disciplinary Letter of Concern –
applicant may have been engage in questionable conduct that is considered low risk or harm to the
public. A letter of concern issued by the Board is non-discipline and is not an appealable agency
action
Disciplinary Actions
combination with any disciplinary action for a violation of the Nurse Practice Act.
Decree of Censure – This is an official discipline by the Board that the individual’s conduct violated
the Nurse Practice Act but does not represent a continued risk to the patient/public.
Probation – This action allows the nurse to continue working during the period of probation
subject to compliance with the terms and conditions. During the period of probation the nurse
must be supervised in their practice and complete certain requirements which are aimed at
rehabilitation or educating and remediating the nurse in his/her area(s) of practice deficit. For
example, a nurse with a substance abuse issue may be required to enter and complete treatment,
attend AA/NA meetings, abstain from alcohol and other drug use along with other requirements.
A nurse who lacks sufficient knowledge of medications or safe administration may be required to
If reason involved criminal conduct then include the
Arrest & Conviction questionnaire.
take a pharmacology course, etc.
Suspension – A person who has been suspended may not practice during the period of
suspension. A person who has been suspended has terms and conditions which must be fulfilled
during the period of suspension and before being allowed to resume practice. Examples of terms
and conditions may include completing a refresher course, psychological or substance abuse
treatment in addition to other requirements. A licensee/certificate holder that has been
suspended often has a period of probation or monitoring following successful completion of the
terms of suspension.
Revocation – This action prohibits the nurse/certificate holder from practicing for a minimum of
five years, pursuant to A.A.C. R4-19-404. When a license/certificate has been revoked, the
applicant for re-issuance must provide detailed information to the Board that the reason for
revocation no longer exists and that the issuance of a license/certificate would no longer threaten
the public health or safety. A.A.C. R4-19-404 or R4-19-815) The individual whose license/certificate
has been revoked may not practice or otherwise indicate to the public that they hold a
license/certificate.
Denial –
eligible to reapply to the Board for a period of five years.
Voluntary Surrender – A Consent Agreement has been signed in which an APRN, RN, LPN, LNA,
CNA has voluntarily surrendered their license or certificate.
Administrative
Violations
Administrative Penalty – A penalty/fine given to a licensee or certificate holder who has worked
on an expired license/certificate, or failed to notify the Board of an address change within 30 days.
It is not reportable to NCSBN or other national data centers.
9. When is the Board decision final?
For discipline to be final and in effect, a Respondent must either consent to the discipline as voted upon by the Board by
signing a “Consent Agreement” or if not signed, the Respondent has had an opportunity for a hearing. Hearings are
conducted at the Office of Administrative Hearings and the person conducting the Hearing is an Administrative Law
Judge (ALJ).
Following the hearing and based upon the evidence presented, the ALJ submits recommended “Findings of Fact,
Conclusions of Law and Order” to the Board. Transcripts of the hearing are reviewed by the Board members prior to
voting on the appropriate disciplinary actions (if any) to be taken. The Board has final authority to determine discipline
and can adopt, modify or reject the ALJ recommendation. If discipline is determined to be appropriate by the majority
of the Board Members, a “Board Order” is issued. If the Respondent disagrees with the outcome, a request for
rehearing must be filed within 30 days of the mailing of the Board’s decision and Order, otherwise, the matter is final.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

REINSTATEMENT QUESTIONNAIRE If reason involved criminal conduct then (Arizona State Board of Nursing)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document