Louisiana State Board of Nursing 17373 Perkins Road, Baton Rouge, LA 70810 Tel: (225) 755-7500 Fax: (225) 755-7581 INSTRUCTIONS FOR APPLYING FOR RN LICENSURE BY ENDORSEMENT Registration in Louisiana is mandatory. It is unlawful for any person to use the title Registered Nurse (RN) or to practice nursing in Louisiana as a Registered Nurse without a license from the Louisiana State Board of Nursing (LSBN). SECTION A: ELIGIBILITY CRITERIA FOR RN ENDORSEMENT 1. Applicant must submit evidence of initial RN licensure from another state, territory, or country; 2. Applicant must submit evidence of current RN licensure issued directly from the jurisdiction of last employment; 3. All applicants must have successfully completed a diploma, associate degree, baccalaureate and/or masters nursing education program approved by one (1) of the following: a. The Louisiana State Board of Nursing, or b. Another U. S. State Board of Nursing in which the program meets or exceeds the nursing educational standards/requirements for nursing programs in Louisiana, or c. A nursing program located in another country (see page 6, SECTION C, for additional requirements). A. If the RN applicant graduated from Excelsior and/or Deaconess College, the applicant must meet the following additional requirements: i. Provide documentation supporting the equivalency of six (6) months to one (1) year full-time clinical experience as a Registered Nurse in a staff position under RN supervision in another U.S. State; AND ii. Have three (3) letters of recommendation for licensure submitted to LSBN. Each letter should be typed, dated and signed by the applicant’s current/previous RN supervisor/employer(s) attesting to the applicant’s ‘satisfactory clinical performance’ and provide verification of RN employment dates and supervisor’s contact information. 4. Applicant must have successfully completed the State Board Test Pool Examination and earned a score of 350 or above in each area –or- have written the National Council Licensure Examination (NCLEX-RN) and earned a passing score of 1600 or “pass” on pass/fail scale. 5. Applicant must not have disciplinary action by any nursing board or other health regulatory board in any state or country with pending stipulations and/or restrictions *; 6. Applicant must not have any civil or criminal charges pending **; 7. Applicant must submit completed application for endorsement, required fees and other required documents within one (1) year; 8. Applicant must submit evidence of proficiency in the English language if a graduate of a nursing program offered in a foreign country; 9. Applicant must submit to a criminal background check (CBC). * Individuals who have past disciplinary action by a licensing board for nurses (RN/LPN/LVN/APRN) or any health regulatory board in any state/province/country, including Louisiana, must provide a detailed, written, signed and dated statement (in their own words) regarding the incident(s) that led to board action including documentation of final outcome. Applicant must contact the board office and request a set of “board certified” documents regarding the action be sent to the LSBN office, Attention: Endorsement Department. Note: Temporary permits will not be granted to the applicant until all documentation has been received, reviewed, and approved by Board staff. ** Individuals who have had any past criminal arrest (even if charges/arrest were later expunged or dismissed) must provide a detailed written, signed and dated statement (in their own words) regarding the details surrounding the arrest(s), judgment and final disposition of the charges on each incident. Send statement along with application. Applicant must also contact law enforcement and clerk of court in the county/parish/jurisdiction where the charges/arrest occurred and request a set of “certified” documents showing: original arrest record, charges, court judgment, and final court disposition of the charges on each incident be sent to the LSBN office, Attention: Endorsement Department. Note: Temporary permits will not be granted to the applicant until all documentation has been received, reviewed, and approved by Board staff. Page 1 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 SECTION B: INSTRUCTIONS FOR COMPLETING FORMS Utilize the current Endorsement Application and forms as listed on the LSBN website at the time you apply. Type or print legibly in (dark blue or black) ink. Answer all questions. If not applicable, indicate N/A. Do not use white-out or correction fluid/film. Attach a passport photo (2” x 2”) to front of application (sign & date back of photo). Endorsement application fees must be paid in the form of a Money Order or Bank Cashier’s Check in the EXACT amount as specified on page 5 of these instructions. The cost of processing the criminal background check is included on totals provided on page 5. Do not submit personal checks or cash. Do not round the total up or down. Application must be signed and notarized on last page - Section VII: Affidavit. Incomplete applications will not be processed for licensure and may be returned for completion. Full disclosure is required in SECTION IV - COMPLIANCE of the endorsement application. Please include any additional documentation as indicated in Section IV along with the endorsement application. Failure to correctly answer questions in this section and self-disclose a ‘yes’ response where applicable may result in disciplinary action, including denial of licensure. 1. FORM END – 1: Application for Licensure as Registered Nurse by Endorsement a. Application must have a current, true Passport ID photo of applicant (signed and dated on the reverse side) attached by a single staple or piece of tape. b. Application must reflect applicant’s complete name, including full middle name, and any previous married name(s) and/or alias(s). Include a note/letter regarding other/previous name(s) that do not fit on application. c. Application must be signed and notarized in Section VII – Affidavit, sworn before a notary public. d. Application must reflect complete/current mailing address(es) for all past nursing employer(s) over the last six (6) years in Section V. Include start and end dates of employment (month/year) for each. If applicant has a gap in nursing employment over the last six (6) years, include a letter of explanation along with application with dates. Applicants will less than six (6) years nursing history - provide employment information since initial RN licensure. e. Please utilize a separate sheet of paper, if necessary, to ensure all requested information is submitted. f. Type/print your first and last name at the top of each page of the application. 2. FORM END – 2: Verification of Licensure Form (see ‘Note’ regarding possible electronic verification) a. Official verification of RN licensure is required from both your: i. Original state where nursing board examination was taken - even if that RN license has since expired or lapsed, - and ii. Current state/province/country where applicant is working at the time endorsement application is submitted to LSBN. If the applicant is currently unemployed, official verification is still required from the Board of Nursing (State BON) where the nurse last worked or last RN licensure was issued. If the applicant’s current/active RN license also happens to be the nurse’s original licensure by examination – then only the one (1) official verification will be needed. NOTE: Many (but not all) State BONs verify RN licensure electronically through www.NurSys.com. Please go first to www.Nursys.com under the ‘Get a License Verified’ section to see if your original and current State BON participates with this electronic verification service. First time users should select ‘View License Verification help video’ at bottom of screen for instructional tutorial. The form END-2 Verification of Licensure Form provided in this application packet would only be used by the applicant if neither their original nor current State BON participates with the www.NurSys.com electronic verification system (see Form END-2). State BONs that still send ‘paper’ verifications must mail them directly to LSBN. b. RN Applicants with previous LPN/LVN licensure: Verification of applicant’s original state of licensure as a LPN/LVN (where applicant took and passed their nursing exam for initial LPN/LVN licensure - even if it is no longer current) is also required. Written verification must be submitted directly to LSBN. Page 2 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 3. FORM END – 3: Nursing Program Data/Verification Form a. Complete the top portion of this form and mail to the school of nursing where applicant’s initial nursing degree (diploma, associate, baccalaureate and/or masters) for initial RN licensure was obtained/conferred. The bottom portion of the form should be completed in full by the school of nursing, including authorized signature and embossed/ink school or college/university seal, and then mailed directly to LSBN, Attn: Endorsement Department, together with an official set of transcripts. Neither the Nursing Data Form nor Transcripts will be accepted from the applicant – even if mailed in a sealed envelope. b. If nursing education was split between more than one institution, LSBN will need an official transcript from each institution; however Form END-3 is required only from the school where initial RN degree was conferred. 4. FORM END – 4: Verification of Nursing Employment (VOE) a. Endorsement applicants are required to have verification of nursing employment submitted directly to LSBN for the last six (6) years of nursing practice as a LPN, RN and/or APRN as follows: i. Applicants with three (3) or more nursing employers over the last six (6) year period – print out an END4 form for each of the applicant’s MOST RECENT THREE (3) nursing employers and complete the top. Forward the END-4 form to the HR Department (or authorized personnel) of each company/agency for them to complete the bottom and submit directly to LSBN. OR ii. Applicants with less than three (3) nursing employers over the last six (6) year period – print out an END-4 form for each nursing employer and complete the top. Forward the END-4 form to the HR Department (or authorized personnel) of each company/agency for them to complete the bottom and submit directly to LSBN. Please note: If the applicant was a travel nurse for any portion of the last six (6) years, his/her agency is the nurse’s employer of record to complete and submit the END-4 form to LSBN for that period of employment. New nursing graduates with no prior LPN/LVN and/or RN work history; write “no nursing employment – new grad” on the endorsement application for SECTION V and submission of END-4 forms is not applicable. 5. CRIMINAL BACKGROUND CHECK (CBC) a. Criminal history records check is authorized under the Nurse Practice Act, Louisiana R.S. 37:920.1 and is a required part of licensure. b. Please see Fingerprint Instructions for Criminal Background Check, Form CBC1(a) Authorization for Criminal Background Check (CBC – Page I) and Form CBC1(b), Authorization for Criminal Background Check (CBC – Page II) to complete the CBC requirement. The CBC documents must be submitted along with the Endorsement Application (Form END-1). The CBC fee mentioned in the Fingerprint Instructions has already been included in the Endorsement Application Fee totals noted on page 5 of these instructions. 6. U.S. SOCIAL SECURITY NUMBER a. All applicants applying for licensure in Louisiana are required to hold a Social Security Card issued by the United States Social Security Administration. Social insurance numbers from Canadian Provinces are not accepted. b. Your social security number is used to verify your identity for licensing purposes as well as compliance with the Federal codes outlined below. All endorsement applicants must include their U.S. social security number on the endorsement application (Form END-1): United States Federal Code (U.S.C.) Title 42, chapter 7, subchapter IV, part D, §666 (a) (13) (A) states: Recording of social security numbers - Procedures requiring that the social security number of – any applicant for a professional license,…(or) occupational license,…be recorded on the application; Additionally, the Code of Federal Regulations (CFR) Title 45, part 61, subpart B §61.7 regarding reporting final adverse actions against health care providers and practitioners states: Federal and State licensing and certification agencies must report to the HIPDB (Healthcare Integrity and Protection Data Bank)… personal identifiers, including social security number Page 3 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 7. QUALIFYING AND REQUESTING A 90 DAY TEMPORARY RN PERMIT a. LSBN offers a 90 day temporary permit, for an additional fee, to qualifying endorsement applicants who reside in Louisiana and have an offer of employment and anticipated start date with a Louisiana facility/institution. The purpose of the permit is to allow the applicant holding an active and unencumbered RN licensure in another U.S. state to start work as a Louisiana ‘RN applicant’ until all documentation has arrived and full RN licensure for the State of Louisiana can be issued by board staff. A 90 day temporary endorsement permit may be requested by individuals who: Can provide a Louisiana residential address where applicant will live while working under the 90 day permit; Have an offer of employment (pending permit being issued) as an RN in Louisiana. Disclosure of Louisiana place of employment must be provided on page 6 of the endorsement application (Form END-1) in SECTION VI – REQUEST FOR A 90 DAY TEMPORARY PERMIT; Hold a current/active and unencumbered RN license from another state or jurisdiction in the United States; Obtained an original nursing degree for RN license from an accredited (LSBN recognized) diploma, associate degree, baccalaureate and/or masters nursing education program in the United States; Wrote the National Council Licensure Examination RN (NCLEX-RN) with a passing score of 1600, or “pass” on a pass/fail scale, or had written a U.S. State Board Test Pool Examination and earned a score of 350 or above on each test area; Have licensure in any other state or jurisdiction not under restriction in any form by any health regulatory board; Have no civil and/or criminal charges pending; Have no cause for denial of licensure as defined in R.S. 37:921 and L.A.C.XLVII. §3331, or allegations of acts or omissions which constitute grounds for disciplinary action as defined in R.S. 37:921 and §3403 and §3405. The following endorsement applicants are not eligible to request a 90 day temporary permit: An applicant who does not reside in Louisiana; An applicant who does not yet have a firm offer of employment from a facility/company located in Louisiana; An applicant whose original nursing education for RN licensure was outside the United States. An applicant who has been issued a 90 day temporary permit in Louisiana previously (1 per nurse, per lifetime). An applicant who has a ‘yes’ answer to any question in ‘SECTION IV – COMPLIANCE’ of the endorsement application (Form END-1) is not eligible for a ‘walk-in’ permit. All requested supplemental documents must be submitted along with application for review to determine licensure eligibility. b. LSBN offers ‘walk-in’ permit processing between the hours of 9:00 am to 3:00 pm central standard time (CST). The applicant must meet all permit eligibility requirements as explained above. Applicants presenting to the LSBN office for a ‘walk-in’ temporary permit will have their fingerprints scanned on-site by board staff (‘LiveScan’) for the required criminal background check (CBC). ‘LiveScan’ fingerprinting must be completed before 3:00 pm CST. The LSBN office is closed for all state and federal holidays. Please try to arrive at the LSBN office by midday to allow sufficient time for processing and be prepared and ready to submit all of the following documents and fees to board staff upon arrival: A fully completed LSBN RN Endorsement Application (Form END-1) which was recently obtained from the LSBN website. All sections of the application must be filled in, with the application both signed and notarized prior to arrival at the LSBN office. Supply one (1) recently taken ‘passport’ photo. Sign and date the back of the photo. A money order or bank cashier’s check for appropriate fee payable to: Louisiana State Board of Nursing (or LSBN). See page 5 for explanation of FEES. Present an original current/valid photo ID such as a U.S. driver’s license (out-of-state is fine) or U.S. issued Passport. Board staff will need to make a photocopy for the applicant’s file. Proof of active RN licensure from your current State Board of Nursing (State BON): If the applicant’s current State BON participates with www.NurSys.com for electronic verification of RN licensure, go to this website 1 to 2 days prior to coming to the LSBN office for ‘walk-in’ permit processing and pay for an ‘official’ verification of licensure report through the ‘Get a License Verified’ option. Print out the ‘receipt’ screen/page from www.NurSys.com showing proof of payment, and provide copy of the receipt to LSBN staff. If applicant’s current State BON does not participate with electronic verification through www.NurSys.com, bring a copy of your current RN license. Page 4 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 8. FEES Fees to apply for RN endorsement license and permits must be paid with a money order or bank cashier’s check, payable to – Louisiana State Board of Nursing (or LSBN). The money order (or bank cashier’s check) must be made out in U.S. dollars for one (1) of the fee totals indicated below. Cost for LSBN to process the required criminal background checks (CBC) are already included in totals. Fee payment must be exact - do not round total up or down. Personal checks, cash and/or credit cards are not accepted. All fees are non-refundable. Please read the full list below to determine which fee total below applies to your RN Endorsement application request. Select only one (1) option. Fee payment must accompany your application. RN Endorsement Application Fee Options (choose only 1 option): $140.75 - Submitting your RN Endorsement Application to LSBN by mail to request a full Louisiana RN licensure but not requesting a 90 day temporary permit. This total includes: $100.00 application filing fee and $40.75 for LSBN to process your fingerprints (on FBI cards) for the required CBC. - OR- $150.75 - Hand delivery of your RN Endorsement Application in person to the LSBN office and having board staff electronically scanned your fingerprints (‘LiveScan’) for the required CBC, but not requesting a 90 day temporary permit. NOTE – If you’ve experienced problems with fingerprinting in the past and live in the Baton Rouge area, you may want to consider this option. Please arrive at the LSBN office well before 3:00 pm (CST) if you choose ‘LiveScan’ fingerprinting. This total includes: $100.00 application filing fee; $40.75 for LSBN to process the required CBC; plus $10.00 for ‘LiveScan’ fingerprinting at the LSBN office (instead of submitting FBI cards with your prints). -OR $240.75 - Submitting your RN Endorsement Application to LSBN by mail to request a full Louisiana RN licensure and requesting a 90 day temporary permit. NOTE – read page 4 carefully for requirements and restrictions to qualify for a 90 day RN temporary permit. This total includes: $100.00 application filing fee; $100.00 additional fee for the 90 day temporary permit; and $40.75 for LSBN to process your fingerprints (on FBI cards) for the required CBC. -OR $250.75 - Hand delivery of your RN Endorsement Application in person to the LSBN office to apply for full Louisiana RN licensure and requesting a ‘walk-in’ 90 day temporary permit while you wait. NOTE – read page 4 carefully for requirements and restrictions to request a 90 day temporary permit. Please arrive at the LSBN office by midday if possible, and before 3:00 pm (CST), to allow sufficient time for ‘LiveScan’ fingerprinting and the processing of your application for the permit. This total includes: $100.00 application filing fee; $100.00 additional fee for 90 day temporary permit; $40.75 for LSBN to process the required CBC; plus $10.00 for ‘LiveScan’ fingerprinting at the LSBN office (instead of submitting FBI cards with your prints). Annual License Renewal and Renewal Fees: Louisiana licenses are calendar year licenses that must be renewed every fall for the next calendar year; regardless of how late in the year licensure was issued. Unlike initial licensure, renewals are processed online through the LSBN website. Once your full Louisiana RN license has been issued, go to ‘My Services’ on the LSBN homepage to establish your private LSBN electronic account (see ‘Nurses Account Signup’). Active renewal season begins in early October and ends on December 31st. A late fee is charged for renewals paid after 11:59pm (CST) on December 31st. All Louisiana nursing licenses automatically lapse at midnight January 31st (CST) if not successfully renewed by the nurse through the LSBN website by that deadline. Fees for license renewed between early October and December 31st (up to 11:59pm CST): $100.00 for RN licensure renewal $200.00 for APRN licensure renewal (includes RN licensure renewal fee) Fees for late license renewal between January 1st until January 31st (up to 11:59pm CST): $150.00 for RN licensure renewal $300.00 for APRN licensure renewal (includes RN licensure late renewal fee) Page 5 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 SECTION C: INTERNATIONALLY EDUCATED NURSES Applicants who are graduates of schools outside the United States are required to have written the State Board Test Pool Examination in accordance with Louisiana Regulations and to have earned a score of 350 or above in each area, or to have written the National Council Licensure Examination for RN’s (NCLEX-RN), in accordance with Louisiana Regulation and have earned a passing score of 1600 or received a “pass” on pass/fail scale. If you have written either of these examinations for licensure in another state or U.S. jurisdiction, please indicate this in a letter submitted along with your application. Official verification of licensure from that State must be submitted directly to LSBN for review. NOTE: Internationally Educated Nurses are not eligible for the 90-Day Temporary Permit. International Nurse Graduates who have not passed the State Board Test Pool Examination or the National Council Licensure Examination for RN’s (NCLEX-RN) and who apply for Louisiana Registration will be required to have written and passed the CGFNS Qualifying Examination given by the Commission on Graduates of Foreign Nursing Schools (CGFNS). Applicant must request CGFNS to send a certified certificate proving that the exam was taken and passed directly to LSBN. The CGFNS Qualifying Exam is administered in the United States of America and over 80 other countries. For more information, please go to the CGFNS website: www.cgfns.org. After all documentation has been received by LSBN, the applicant will be notified by mail if they are eligible to sit for the required NCLEX-RN exam. If you are already licensed in another U.S. State and have written and passed the National Council Licensure Examination for RN’s (NCLEX-RN), you must still have your school transcripts evaluated by the GCFNS and obtain a Credentials Evaluation Service Professional Report (CESPR) which analyzes international education and licensure in terms of United States comparability. Contact CGFNS to apply for the CESPR report and have a certified copy sent directly to LSBN by CGFNS. LSBN also requires International Nurse Graduates to take (or have taken) the Test of English as a Foreign Language (TOEFL) and achieved a CGFNS acceptable passing score. CANADIAN EDUCATED NURSES - if you wrote the National Council Licensure Examination for RN’s (NCLEX) or the Canadian Nurses Association Testing Service Examination (CNATS), written in the English language, please indicate this in a written note/letter to accompany your application. The END-2 Verification of Nursing License form must be completed by your original Canadian province and mailed to LSBN to confirm Canadian Board test results and score. The END-2 Verification of Nursing License form will also be required from the U.S. State where the NCLEX had been taken (if applicable), as well as current state/province (if different). If you graduated from a Canadian Nursing School with only a ‘PASS’ result on the Canadian Board Exam (CNATS) and not an actual score, or if the test was not taken in English, the applicant will be required to sit & pass the NCLEX-RN exam unless already taken as part of licensure for another U.S. state. If applicant had received one ‘single integrated’ score on the CNATS Exam, a minimum score of 400 is required. If the Canadian Board Exams taken had issued ‘individualized scores by area of nursing’, then a minimum of 350 in each area is required, otherwise the applicant will have to take & pass the NCLEX-RN exam. PLEASE NOTE - ALL applicants for RN endorsement, whether U.S. citizen or not, are required to hold a United States Social Security Card authorizing them to work in the United States before RN Licensure can be issued. INSTRUCTIONS FOR SUBMISSION OF DOCUMENTS & PROCESSING BY INTERNATIONALLY EDUCATED NURSES 1. If you do not already hold a U.S. Social Security card, contact the U.S. Social Security Administration directly and apply for one at www.ssa.gov. This process can be lengthy and should be started as soon as possible. A U.S. Social Security card is a mandatory part of the LSBN’s RN licensure process and should be included with your application. RN licensure will not be issued until the SS card/number has been obtained by applicant. 2. Applicant to provide along with application photocopy of a U.S. Residency Card or Green Card. LSBN will also accept a certified VisaScreen certificate issued by Commission on Graduates of Foreign Nursing Schools. VisaScreen certificate must be mailed directly to LSBN by CGFNS. 3. If you had taken and passed the CGFNS Qualifying Examination, attach a photocopy to your application and contact CGFNS for a certified certificate/report of the exam to be mailed directly to LSBN by CGFNS. 4. If you are licensed in another State in the U.S. by NCLEX examination, but did not take the CGFNS Qualifying Exam at some point in your nursing career, contact CGFNS to apply for a Credentials Evaluation Service Professional Report (CESPR) and have a certified copy mailed directly to LSBN by CGFNS along with evidence of successful score/completion of the TOEFL (English proficiency examination). The CESPR will replace the Nursing Data Form & Transcripts from your School of Nursing. 5. Complete all applicable forms as directed under “Section B” in these instructions Page 6 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 SECTION D: SPECIAL INFORMATION FOR ALL APPLICANTS ► PLEASE READ ALL INSTRUCTIONS CAREFULLY Incomplete applications will be returned to the applicant for proper completion. ► Application forms and fees are subject to change. Applicants must utilize and submit to LSBN the current endorsement application forms as posted at the LSBN website www.lsbn.state.la.us at the time the nurse applies. Submitting either out-of-date application form(s) and/or an incorrect fee will result in the delay in the processing of your application and may result in it being returned unprocessed. ► Louisiana nursing licenses are calendar year licenses which once issued, must be renewed by the nurse each fall for the next calendar year. Please take note of the following: Once the applicant’s full Louisiana RN license has been issued, the nurse should go to ‘My Services’ at the LSBN homepage and establish a private LSBN electronic account (see ‘Nurses Account Signup’). This is required to update contact information as it changes, as well as access to the online renewal system. Annual license renewals must be completed online by the nurse. ‘Paper’ renewal applications are not available. The online application includes sworn attestation statements that must be answered directly by the RN. Active renewal season begins in early October and ends on December 31st. Nurses may still renew their Louisiana RN license in January, but a late renewal fee(s) will be charged after 11:59pm (CST) on December 31st. All licenses automatically lapse at midnight January 31st (CST) if not successfully renewed by the nurse online by that deadline. Unlike initial licensure, online renewal fees must be paid online by credit card. Due to banking security issues, LSBN is unable to process online renewals paid with a ‘debit’ card. If an endorsement applicant is applying for a Louisiana RN license in order to start work in beginning of a new calendar year - but is submitting the endorsement application and fees prior to January 1st, then the applicant should include a letter requesting “application held for license issuance until mid-January” of the following year once application file is complete. Due to holiday office closures, Board staff cannot provide a specific date licensure can be issued in January. NOTE: Applicants requesting ‘January file hold’ for next year’s license should not submit their application earlier than mid-November. During the first year of licensure, Louisiana RN Licensees are exempt from the nursing continuing education (CE) requirement. However, completion of ANCC or State Board of Nursing accredited nursing CEs will be required for each following year to qualify for annual license renewal. To read LSBN CE requirements, click here. ► Money Order or Bank Cashier’s Check for endorsement fees must be in the exact amount indicated on the FEES section (page 5) of these instructions. Do not submit cash or personal checks. Do not round the fee up or down. The totals outlined in the FEES section already include the additional cost for processing the required criminal background check as noted on the ‘Fingerprint Instructions’. ALL FEES ARE NON-REFUNDABLE. ► Nursing Program Data Form and/or Transcript submitted by the applicant or any third party, other than from the school directly to our board will not be accepted. If your School of Nursing is now closed, have the organization that now holds those records submit this documentation. Applicant should include a short letter with his/her application explaining nursing school is closed and what institution will be submitting the documents. ► If you are a nurse graduate of a non-traditional nursing program such as EXCELSIOR COLLEGE (formerly known as ‘New York Regents College’) or DEACONESS COLLEGE, contact the LSBN’s Endorsement Department at [email protected] to determine your eligibility for RN licensure in Louisiana before submitting an application. ► Positive work references are required for RN licensure by endorsement. ► Failure to disclose and/or falsification of any information on the application, forms or other documents submitted to LSBN is cause for denial of licensure in Louisiana and can result in disciplinary action. ► Applications not completed within one (1) calendar year from the date received at LSBN will be closed. Page 7 of 7 Revised: 6/11, 3/12, 1/13, 9/15/14, 9/20/14, 2/01/15 SBN OFFICE USE ONLY: ATTACH HERE (single staple or piece of tape on edge of photo) APPROVED BY (initial)__________________________________ One passport size (approximately 2 x 2), fadeproof, passport identification photograph made within the last six (6) months. On the back of picture, sign and indicate date photo was taken. DATE APPLICATION RECEIVED_________________________ PERMIT NUMBER______________________________________ DATE PERMIT ISSUED _________________________________ DATE PERMIT EXPIRES ____________________________________ LOUISIANA STATE BOARD OF NURSING 17373 Perkins Road, Baton Rouge, Louisiana 70810 Telephone 225-755-7500 E-mail: [email protected] END FORM 1: Application for Licensure as Registered Nurse (RN) by Endorsement APPROPRIATE FEES MUST BE SUBMITTED ALONG WITH THIS APPLICATION Please read the full Instructions for Applying for RN Licensure by Endorsement before submitting this application to ensure you are eligible to apply. Page 5 of the Instructions outlines the applicable total fee to submit along with this application. Money Order or Bank Cashier’s Checks only. Personal Checks or Cash are not accepted. Fees are NOT refundable Applications not completed within one (1) year from date of submission will be closed and cancelled. SECTION I. CONTACT INFORMATION (Type/print Legibly – To be completed by Applicant) 1. Name: _____________________________________________________________________________________________ 2. Current/Permanent Mailing Address (wall certificate will be mailed to this address once RN license has been issued): First Middle Maiden/Last Married ___________________________________________________________________________________________________ Street City State Zip Code Louisiana residential address - required if applicant is requesting a 90 day temporary permit (see Instructions, page 4): ___________________________________________________________________________________________________ Street 3. City State Zip Code Telephone #:______________________________ U.S. Social Security #: _______________________________________ Cell Phone #:______________________________ E-mail address: ____________________________________________ 4. Date of Birth ________________________ City & State of Birth: ______________________________________________ 5. Are you a citizen of the United States? Yes - or No - If no, give Alien Registration #: _____________________ SECTION II. EDUCATION (Type/print Legibly – To be completed by Applicant) 1. Name, city and state of high school: __________________________________Graduation Date: ______________________ 2. Name, city and state of original/first school of nursing for RN degree: ___________________________________________ _________________________________Date of entrance: ________________Date of Graduation: ____________________ Associate Degree: Diploma: Baccalaureate: Masters or Higher: NOTE: You may not practice in Louisiana, as defined in the Nurse Practice Act, LA R.S. 37:911 et seq., until you have filed an application and have been issued a 90 day temporary permit or renewable full RN nursing license from the Louisiana State Board of Nursing (LSBN). FORM NBR: END – 1 Page 1 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST name at the top of each page): ____________________________________________ 3. 4. List additional study and/or academic preparation beyond basic RN nursing program: ______________________________________________ _____________________________________________ ______________________________________________ _____________________________________________ ______________________________________________ _____________________________________________ If originally licensed as an LPN/LVN, provide the name, city and state of the LPN/LVN nursing school/program completed: __________________________________________________________________________________________ Date of entrance: ____________________ 5. Date of Graduation: ____________________ Are you currently licensed or authorized to practice as an Advanced Practice Registered Nurse (APRN) in another State or jurisdiction ?(check all that apply): Certified Nurse Midwife (CNM): Clinical Nurse Specialist (CNS): Certified Registered Nurse Anesthetist (CRNA): Nurse Practitioner (NP): NOTE: If you answered ‘yes’ to any of the above, you must request and submit an application for licensure as an Advanced Practice Registered Nurse (APRN) by endorsement for Louisiana together with this application for RN licensure. SECTION III. LICENSURE HISTORY (Type/print Legibly – To be completed by Applicant) 1. My original/first licensure as a Registered Nurse (RN) was issued by the State or jurisdiction of _____________________________________ on __________________________(date) and was assigned registration/license number___________________________. The status of this original RN licensure is: Active/Current 2. Inactive or Lapsed List ALL other states/jurisdictions in which you have ever been licensed as an LPN/LVN, RN or APRN, beginning with the state/jurisdiction of most recent employment. (Attach additional sheet if necessary). U.S. State or Jurisdiction Type of License (circle one) Date of Registration License Number Licensure Status (circle one) LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive LPN / RN / APRN Active / Inactive . FORM NBR: END – 1 Page 2 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST): ______________________________________________________________ SECTION IV. COMPLIANCE (Type/print Legibly – To be completed by Applicant) YOU ARE HEREBY DIRECTED TO DISCLOSE ALL APPLICABLE MATTERS AS FOLLOWS: 1. Yes__No__ Have you ever been issued any of the following: a citation or summons for, and/or has/have warrant(s) been issued against you related to, and/or have you been arrested, charged with, arraigned, indicted, convicted of, and/or pled guilty/”no contest”/nolo contendere/“best interest” or any similar plea to, and/or been sentenced for any criminal offense, including all misdemeanors and felonies, in any state or other jurisdiction? NOTE: Even though an arrest or conviction has been pardoned, expunged, 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. - DWI arrest must be reported, regardless of final disposition. - Traffic violations such as speeding or parking tickets do not need to be reported. If the above question was answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) with date of any/all citations, summons, warrants, arrests, charges, arraignments, indictments, convictions, pleas, sentence, the name of parish/county in which arrests, etc., occurred, the names of arresting agencies, the violation(s) listed, the final disposition of any/all criminal matters, and current status, if no final disposition. Enclose certified true copies of any/all arrest report(s), etc., occurrence/narrative/supplemental reports; certified true copies of any/all court minute entries and court judgments/orders; copies of probation/DA diversion or Pretrial Intervention programs, etc., and any/all other relevant records. 2. Yes__No__ Have you 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? and/or Have you had disciplinary action pending by a licensing board – other than by the Louisiana State Board of Nursing - in any state or jurisdiction? If either of the above questions were answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) with 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, Enclose certified true copies of any/all other board actions by other licensing boards, along with any/all related and/or subsequent actions. 3. Yes__No__ Have you been discharged from the military on ground(s) other than an honorable discharge? If the above question was answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) of 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. FORM NBR: END – 1 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. Page 3 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST): ___________________________________________________________ 4. Yes__No__ Have you been named as a defendant in a civil/malpractice case relating to your practice of nursing? and/or Has a medical review panel opinion been rendered relating to your practice of nursing? and/or Have you been reported to the National Practitioner Data Bank? and/or Have your clinical privileges been suspended, revoked, restricted or limited? If any of the questions above were answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) with date(s) of incident(s) involved, detailed description of the incident(s) at issue along with description of the surrounding circumstances, information regarding the current status of the Medical Review Panel opinion, civil or medical malpractice suit(s), and any/all other relevant information. Enclose photocopies of any/all Medical Review Panel opinions, civil or medical malpractice suit(s), along with any/all related records. 5. Yes__No__ Have you 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 the above question was answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) 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, currentlyprescribed medication(s), and any/all other relevant information. Include in your statement if you are going to apply, or have applied, for Social Security or insurance disability. 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, along with any/all related records. 6. Yes__No__ Have you had a problem with, been diagnosed as dependent upon, or been treated for mood-altering substances, drugs or alcohol? and/or Have you been diagnosed as dependent upon, addicted to, or been treated for, dependence upon medications? If either of the above questions were answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a narrative explanation (dated and signed) 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, currentlyprescribed medication(s), and any/all other relevant information. Include in your statement if you are going to apply, or have applied, for Social Security or insurance disability. FORM NBR: END – 1 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, along with any/all related records. Page 4 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST): ___________________________________________________________ 7. Yes__No__ Have you filed an application for license/registration in another state/jurisdiction but were denied licensure? If the above question was answered ‘Yes’, then Yes__No__ Have you previously reported/provided the following information to the Louisiana State Board of Nursing? If you answered ‘No’ here, and/or had not reported/provided the following, then submit with application: Provide a detailed written explanation regarding where you applied, when, type of registration/ licensure applied for, and why it was not issued. Enclose certified true copies of any/all relevant documents from that state/jurisdiction regarding the denial. 8. Yes__No__ Have you ever filed an application for licensure as a Registered Nurse in Louisiana before? If the above question was answered ‘Yes’, then Provide a written statement stating the approximate date/year you applied and reason why you had not completed the application process and obtained RN licensure. 9. Yes__No__ Were you ever licensed as a Registered Nurse in Louisiana? If yes, STOP HERE. You must apply to the Louisiana State Board of Nursing for Reinstatement of your previous RN license. (Reinstatement instructions and forms are available at the LSBN website) 10. Yes__No__ Have you ever been licensed in a country other than the United States? If yes, please specify the name and address of the authority who issued that original registered nurse license: ____________________________________________________________________________________ 11. _________ In what U.S. State and/or jurisdiction are you currently working as an RN - or - last worked as an RN Provide State if you are not currently employed? (response required) _______________________________________ SECTION V. NURSING EMPLOYMENT HISTORY AND VERIFICATION (Type/print Legibly – To be completed by Applicant) Provide all nursing employment history for the last six (6) years below. Type/print each company name and their full mailing address, including zip code, start and end dates (in month/year format), attach an additional sheet if necessary. List current or most recent nursing employment first. If employed through a nurse agency, provide their information. If applicant has a gap in nursing employment over the last six (6) years, include a letter of explanation (with dates) along with application. Applicants with less than six (6) years nursing history - provide any nursing employment since initial RN/LPN licensure. If applicant is not eligible for rehire, submit a signed letter of explanation along with application. VERIFICATION OF NURSING EMPLOYMENT IS REQUIRED FOR LICENSURE. See form FORM END – 4: Verification of Nursing Employment. This is the only endorsement application form that will be accepted by fax, but must be submitted directly to LSBN by the nursing employer. Institution or Agency Name Complete Address with Zip Code Start and End Dates of Employment Position Held Eligible for Rehire? _________________________________________________________________________________________ Yes-___ No-___ _________________________________________________________________________________________ Yes-___ No-___ _________________________________________________________________________________________ Yes-___ No-___ _________________________________________________________________________________________ Yes-___ No-___ _________________________________________________________________________________________ Yes-___ No-___ _________________________________________________________________________________________ Yes-___ No-___ FORM NBR: END – 1 Page 5 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST): ___________________________________________________________ SECTION VI. REQUEST FOR A 90-DAY TEMPORARY PERMIT (Type/print Legibly) To be completed by the Applicant IF requesting a Temporary Permit If you wish to be employed in Louisiana as an RN Applicant while your endorsement application is being processed for full RN licensure, complete this section and provide all information below together with the additional permit fee(s) noted in the endorsement instructions. The 90 day temporary permit is applicable to those individuals who: Have an offer of employment as an RN in Louisiana and can provide that contact information below; Hold a current/active unencumbered RN license from another jurisdiction in the United States; Reside in the State of Louisiana and provide that address on the front page of this application; Original nursing degree (diploma, associate, baccalaureate, or masters) for RN license was obtained from an accredited nursing school in the United States and meets or exceeds nursing educational standards/requirements of LSBN; Wrote the National Council Licensure Examination RN (NCLEX-RN) with a passing score (or had written a U.S. State Board Test Pool Examination and earned a score of 350 or above on each test area); Whose license in any other state or jurisdiction is not under restriction in any form by any health regulatory board; The individual has no civil or criminal charges pending; There is no cause for denial of licensure as defined in R.S. 37:921 and L.A.C.XLVII §3331, or allegations of acts or omissions which constitute grounds for disciplinary action as defined in R.S. 37:921 and §§3403 and 3405. A notarized photocopy of both a current photo ID (active driver’s license or passport) and a current RN license from your last state/jurisdiction must accompany this application. If you hold an active license from your original state of RN licensure, submit a notarized photocopy of that license as well. I, _____________________________________________________________, am submitting my current/active RN license from First Middle Maiden Married the State of _____________________________________, and request to be issued a 90-Day Temporary Permit to practice as a RN Applicant in Louisiana pending permanent RN licensure/registration. I anticipate nursing employment at the following Louisiana facility: ______________________________________________________________________________________________________ Hospital/Facility/Institution Address and City in Louisiana Anticipated Start Date The offer of my RN employment at the above Louisiana facility is as a: (one below must be marked/supplied) Direct hire for the facility: OR Placement through the following nursing agency (provide the agency name, recruiter name and phone number): ___________________________________________________________________________________________________ Affidavit on the following page (SECTION VII) must be completed/notarized by all endorsement applicants, regardless if a 90 day temporary permit is being requested. FORM NBR: END – 1 Page 6 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Name of Applicant (type/print FIRST and LAST): ___________________________________________________________ SECTION VII. AFFIDAVIT MUST BE COMPLETED/NOTARIZED FOR ALL APPLICANTS THIS AFFIDAVIT SECTION MUST BE COMPLETED BY ALL APPLICANTS, WHETHER OR NOT A TEMPORARY PERMIT IS BEING REQUESTED. I, ____________________________________________, being duly sworn, state that I am the person referred to in this application for licensure as a Registered Nurse by endorsement in the State of Louisiana; that the statements herein contained are true in every respect; that I have read and understand this affidavit. Failure to disclose and/or falsification of any information accompanying or contained on this application will result in denial of licensure and may result in disciplinary action. I hereby authorize the Louisiana State Board of Nursing to conduct a criminal records check and hereby authorize the Louisiana State Police and the Federal Bureau of Investigations to release all criminal record information maintained in their files, which may confirm or deny my eligibility for licensure. _____________________________________________ Signature of RN Endorsement Applicant Sworn to before me, this ___________ day of _______________________________, 20____. ___________________________________________ Signature of Notary Public (NOTARY SEAL) NOTARY - IMPRINT THIS PAGE ONLY ____________________________________________ Printed Name of Notary Public Commission Expires__________________________ State of ____________________________________ Parish or County_____________________________ FORM NBR: END – 1 Page 7 of 7 Revised: 8/10, 12/10, 6/11, 3/12, 1/13 Louisiana State Board of Nursing 17373 Perkins Road, Baton Rouge, LA 70810 Main Tel: (225)755-7500 FORM END – 2: Verification of Nursing License To Applicant: Go to www.NurSys.com first to see if original licensure state (by examination) and current state of RN license is a participating member for official verification. If one (or both) are not participants with NurSys verification – contact the Board of Nursing for applicable fee to be mailed with this form. Applicant completes/signs top section only. I am applying for licensure as a Registered Nurse in Louisiana by Endorsement, and this Board requires official license verification. Name: ____________________________________________________________________________________________________ First Name Middle Name Maiden Name Current/Married Name I was granted License Number: ___________________ on (date): _________________ by the State of ______________________ By signing below, I hereby authorize the _______________________ State Board of Nursing to furnish the Louisiana State Board of Nursing in writing any pertinent information, favorable or otherwise, regarding my licensure in your jurisdiction as requested below. _____________________________________ Applicant’s Signature _______________________________ ____________________ Social Security Number Date Instructions to State Board of Nursing: Please complete the bottom portion of this form (or attach your BON verification report) for the above Registered Nurse Applicant. Mail the official verification directly to the Louisiana State Board of Nursing, ATTN: RN Endorsement Dept. Thank you. This is to certify that the above nurse is/was issued the following nursing license(s) as indicated below (fill in and circle): Type of License License Number Date of Licensure/ Registration Expiration Date Basis of Licensure Is Disciplinary Action Pending? Is License Encumbered or had Past Action? LPN / LVN Exam / Endorsement No / Yes * No / Yes * RN Exam / Endorsement No / Yes * No / Yes * * If yes, attach Board certified copy of any/all related documents to this verification. S.B.T.P.E. Test Results if Licensed by Exam: (or NCLEX Exam result when score value was issued, instead of ‘Pass/Fail’) Series # _________ Medical Nursing Score for each area: _________ Psychiatric Nursing Obstetric Nursing Surgical Nursing Nursing of Children _________ _________ _________ _________ OR NCLEX Exam Score ___________ Number of times applicant wrote examination: ______ Dates Taken: ___________; ___________; ___________; ___________ If applicant did not write either the SBTPE or NCLEX exam, but qualified for initial license by other exam method, please indicate ‘Other’ above and provide the information regarding name of test taken, test plan, and score on reverse side or attach to this form. Canadian Nurse Graduates (only): C.N.A.T.S. Exam Score: ________________; Exam taken in English? Yes - or No - Name of Nursing Program/School completed: ___________________________________________________________________ School Location (city/state): ___________________________________________________Year of Graduation: ________________ Was this school accredited by this Board at the time of the candidate’s graduation / licensure? Yes - or No - Board Seal Here FORM NBR: END - 2 ___________________________________________________ Signature Date Revised: 8/10, 12/10, 6/11, 3/12 Louisiana State Board of Nursing 17373 Perkins Road, Baton Rouge, LA 70810 Main Telephone: (225)755-7500 FORM END – 3: Nursing Program Data/Verification To Applicant: Complete top section of this Form END-3 and send to nursing school for completion. Both a completed END-3 form and an official set of transcripts must be mailed directly to LSBN from the university/institution where applicant obtained his/her initial RN degree. Contact school to determine if fee is required. To: Dean or Assistant Dean of Nursing Program From: Former Graduate (print all information) - ________________________________________________________________________________________ First Middle Maiden LAST NAME at Time of Graduation: _______________________________ Current Last/Married Name Graduation Date: __________________________ Current Address: __________________________________________________________________________________________ Street City Social Security Nbr: _____________________________________________ State / Country Zip Date of Birth: __________________________ Name of Nursing School: ______________________________________________________________________ Mailing address of School: _____________________________________________________________________ Instructions to School of Nursing: Please complete the bottom portion of this form for the above past graduate of your nursing program and mail directly to the Louisiana State Board of Nursing. An official set of transcripts is also required and may be sent together with this form or separately. Please indicate: ATTN: RN Endorsement Dept. Please include your school seal where indicated at the bottom. Thank you. Date of Admission: __________________ Date of Graduation: ___________________ Length of Program:_________ /yrs Type of RN degree conferred: Diploma - Associate Degree - Baccalaureate - Masters or Higher - Did the RN Program include instruction in Behavioral, Biological, Mathematical, Nursing and Physical Sciences? Yes - or No - Did the student have clinical learning experiences with clients having nursing care needs in all age groups and stages of the healthillness continuum as appropriate to the role expectations of the graduate? Yes - or No - Please provide the name(s) of the accrediting/approval bodies for the program at the time of the individual’s graduation: Board of Nursing: _____________________________ Regional Accrediting Body: _____________________________________ National Nursing Accrediting Body: Did applicant presented evidence of High School graduation or equivalency: Yes - or No - I certify that the record of the above graduate on file in this nursing program gives me a basis for recommending him/her for registration as Registered Nurse (RN) in the State of Louisiana. SEAL of program, college or university here ___________________________________________ Signature Date signed ___________________________________________ Title FORM NBR: END - 3 Revised: 8/10, 12/10, 6/11, 3/12 Louisiana State Board of Nursing 17373 Perkins Road, Baton Rouge, LA 70810 Main Tel: (225)755-7500 Fax: (225) 755-7581 FORM END – 4: Verification of Nursing Employment To Applicant: Form END-4 must be completed/signed by the HR Department (or authorized personnel) as follows: Applicants with three (3) or more nursing employers over the last six (6) year period – completed END-4 form required from each of the MOST RECENT THREE (3) nursing employers, OR Applicants with less than three (3) nursing employers over the last six (6) year period – completed END-4 form required from each nursing employer. Applicants completes/signs top section before sending an END-4 form to each employer. The completed/signed END-4 forms must be sent directly to LSBN by the employer – but may be faxed to the number provided above. To: ______________________________________ PLACE OF NURSING EMPLOYMENT / AGENCY _________________________________________ NAME OF SUPERVISOR I, ________________________________________________, Social Security Nbr: ______________________________________ (Name of Nurse/Applicant) have applied to the Louisiana State Board of Nursing for licensure as a _____________ nurse. I have stated on my application that (RN / APRN) I am/was employed at your institution/company as a ________________ nurse for the following period (LPN / RN / APRN) From: __________________________________ to __________________________________ . (approximate start/hire date) (Last day worked or ‘Present’ if still employed) I hereby authorize you to release to the Louisiana State Board of Nursing for licensure purposes, the information requested below. ________________________________ Date _________________________________________________________ Signature of Applicant ATTENTION: THIS FORM WILL NOT BE ACCEPTED DIRECTLY FROM THE APPLICANT Instructions to Nursing Employer(s): The above named person has applied for licensure as a nurse in the State of Louisiana and has given your name as a reference. Please furnish the information requested below and return the completed form by mail or fax directly to: Louisiana State Board of Nursing (LSBN) / ATTN: Endorsement Dept, 17373 Perkins Road, Baton Rouge, LA 70810 1. The above applicant is/was employed from: ______________________________ to __________________________________ (Hire/Start Date) As a(n): (Last Day Worked or ‘Present’ if still employed) RN - LPN - NP - CRNA - CNS - CNM - Other: - If ‘Other’ specify job title in space below and provide list job duties together with this form. __________________________________________________________________________________________ 2. GENERAL WORK HISTORY: Met performance requirements - Performance NOT satisfactory - ________________________________ Date (If NOT satisfactory, please provide explanation) _________________________________________________________ Signature and Title of Supervisor Completing Form EMPLOYER/COMPANY: ________________________________________________________________________ MAILING ADDRESS: ________________________________________________________________________ PHONE and FAX NUMBER: ________________________________________________________________________ FORM NBR: END - 4 12/12, 6/11, 3/12 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 2) Fingerprinting: Contact your state or local police/sheriff’s office to inquire about their procedures, fees and locations for fingerprinting services. You will need to be fingerprinted onto two (2) official Federal Bureau of Investigation (FBI) fingerprint cards. If your local law enforcement office does not have blank FBI cards, LSBN board staff can mail you a set of FBI cards upon written request. Fill out the Request for Blank Fingerprint Cards form, indicate which department you will be submitting the CBC (and application, where applicable) at the top of the form, and fax to LSBN. If providing the CBC fingerprints cards & authorization sheets to apply for initial licensure or reinstatement in Louisiana, they must accompany your application. 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 (1st) FBI card, then scan your hands again to print your fingerprints on the second (2nd) 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: 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. 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. 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. 3) Fees due LSBN for CBC: $40.75 – Payable to Louisiana State Board of Nursing (LSBN) if paper FBI fingerprint cards are submitted - OR – $50.75 – 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). All fees 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 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): $40.75 – Payable to Louisiana State Board of Nursing (LSBN) if paper FBI fingerprint cards are submitted - OR – $50.75 – 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, MSN, RN FACILITY OR AGENCY FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE Cynthia York, RN, MSN, CGRN FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE 17373 Perkins Road MAILING ADDRESS SIGNATURE OF LSBN AUTHORIZED REPRESENTATIVE Baton Rouge, LA 70810 (225) 755-7500 CITY ZIP CODE FACILITY OR AGENCY PHONE NUMBER STATE 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 Revised: 2/08, 6/11, 3/12, 2/15 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: PLEASE PRINT OR TYPE INFORMATION, AGENCY EXCLUDING ADMINISTRATORS OR AUTHORIZED PERSON SIGNATURE. INCOMPLETE FORMS WILL NOT BE PROCESSED. 17373 Perkins Road MAILING ADDRESS Baton Rouge LA CITY STATE 70810 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 Revised: 2/08, 6/11, 3/12, 2/15 Louisiana State Board of Nursing 17373 Perkins Road, Baton Rouge, LA 70810 Telephone: (225) 755-7500 Credentialing Fax Number: (225) 755-7581 www.lsbn.state.la.us REQUEST FOR BLANK FINGERPRINT CARDS I am required to submit to a Criminal Background Check (CBC) as authorized by the Nurse Practice Act, Louisiana Revised Statutes 37:920.1. I am unable to obtain Federal Bureau of Investigation (FBI) cards from my local law enforcement agency; therefore I am requesting two (2) blank fingerprint cards to be mailed to me by the Louisiana State Board of Nursing (LSBN). Please indicate the department you will later be submitting an application for Louisiana licensure for this request of blank FBI cards. Check the appropriate box, complete the form below (please PRINT) and fax to the number listed above. ✔ - RN Licensure by Endorsement (already licensed as an RN outside of Louisiana) - RN or APRN Licensure by Reinstatement (I held a Louisiana RN or APRN license previously) - APRN Licensure by Endorsement or Examination Full Name: ___________________________________________________________________________ Mailing Address – Street: ______________________________________________________________________________ City: ____________________________________ State: ___________ Zip:__________________ Home Phone Number: __________________________________________________________________ Work Phone Number (include extension): ____________________________________________________ Cell Phone Number: ___________________________________________________________________ E-mail Address: _______________________________________________________________________ NOTE: If applying for initial Louisiana licensure, do not submit your application until you have received and completed the FBI fingerprint cards. Your full CBC packet must accompany your application. If applying for license reinstatement, refer to instructions and application to determine if a CBC packet is required to accompany your application. Revised: 2/08, 6/11, 3/12, 2/15
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