Nursing Endorsement Application Dpr Delaware Form

CANNON BUILDING 861 SILVER LAKE BLVD. SUITE 203 DOVER DELAWARE 19904-2467 STATE OF DELAWARE DEPARTMENT OF STATE DIVISION OF PROFESSIONAL REGULATION BOARD OF NURSING TELEPHONE 302 744-4500 FAX 302 739-2712 WEBSITE DPR*DELAWARE*GOV EMAIL customerservice. Dpr state. de. us APPLICATION FOR LICENSURE AS AN RN OR LPN BY ENDORSEMENT INSTRUCTION SHEET Please read all instructions carefully before completing and submitting your application* Failure to follow instructions may result in a delay of licensure. When to File Application by Endorsement Complete this application only if all of the following apply to you You hold a current active Nursing license of the same type in another jurisdiction state U*S* territory or District of Columbia. You have never held a Delaware Nursing license of the same type. You are not a resident of a compact state listed below OR you currently reside in a compact state listed below but plan to move to Delaware or to a non-compact state. COMPACT STATES Arizona Arkansas Colorado Delaware Idaho Iowa Kentucky Maine Maryland Mississippi Missouri Nebraska New Hampshire New Mexico North Carolina North Dakota Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Wisconsin If you have ever held a Delaware license complete the Application for Reinstatement of RN or LPN License instead* If you never held a Delaware RN/LPN license and do not hold a current active RN/LPN license in another jurisdiction contact the Board office for guidance. Requirements for All Applicants Submit completed signed and notarized Application for Licensure as a Registered Nurse or Practical Nurse by Endorsement. Make sure all questions are answered unless the instructions tell you to skip a question* Read the AFFIDAVIT section* Sign the application in front of a notary public* Forms that are incomplete unsigned or not notarized will be rejected* Enclose processing fee by check or money order made payable to State of Delaware. Applications submitted without this processing fee will be rejected* Enclose a copy of your driver s license or official identification card from the Division of Motor Vehicles. Enclose a photocopy of your current nursing license from another jurisdiction* You may send a printout of your state s online verification if it shows the expiration date. License must show an expiration date. If there is a signature section on your license sign it before copying. If the other jurisdiction where you are currently licensed is not a nurse licensure compact state listed below your license must remain current throughout the entire endorsement process. The compact states are New Hampshire New Mexico North Carolina North Dakota Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Wisconsin Revised 10/2012 Complete the Authorization for Release of Information form to request a criminal background check. Follow the instructions on the authorization form to arrange to be fingerprinted* You must complete this requirement even if you recently had a criminal background check done for some other reason* most recent six months of your nursing practice. If you are a recent graduate send the form to your school for processing* After completing the form the employer s must return the form directly to the Board office. Forms received from you will be rejected* If the Board office receives an incomplete Employer Reference Form from your employer because it is your employer s policy not to comment on performance the Board office will contact you to submit a copy of your most recent employee evaluation* Obtain this evaluation yourself do not ask your employer to forward a copy. This is needed in addition to not instead of the Employer Reference Form* Provide verification of original licensure by examination* How you do this depends on whether the jurisdiction where you were licensed utilizes the NurSys databank. Jurisdictions that utilize NurSys are Alaska American Samoa Arizona Arkansas Colorado District of Columbia Florida Guam Idaho Indiana Iowa Kentucky Louisiana-Registered Nurse Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia-Practical Nursing Wisconsin Wyoming If your original jurisdiction of licensure is listed above go to www. Nursys. com and complete the NurSys Verification Request. send it to the Board of Nursing in the jurisdiction where you were licensed by examination* Contact that jurisdiction to find out if there is a fee. If you graduated from a nursing program outside the United States provide a copy of your CGFNS certificate. Security Number Requirement. The Privacy Act of 1974 Section 7 requires the following information to be given to all applicants Applicants for any Delaware professional or occupational license permit registration or certificate other than Gaming permits are required to provide a U*S* SSN 29 Del* C. 8735 m. The Division of Professional Regulation uses the SSN primarily to verify identity and safeguard personal information* It may also be used to enforce child support obligation 13 Del* C. 2216 and for other lawful purposes. Apply for a Temporary Permit only if you have an offer of employment and plan to start employment in Delaware before the endorsement process is completed 4-6 weeks. Complete the TEMPORARY PERMIT section of the application* Do not begin orientation or employment until you are assigned a temporary permit number. If you are also applying for an APN license and need an APN Temporary Permit apply only for the APN Temporary do not complete the TEMPORARY PERMIT section of the Endorsement application* Enclose temporary permit fee by check or money order made payable to State of Delaware. This fee is in addition to the processing fee for the application* There is no additional fee for a permit extension* The Board office must receive results of the criminal background check before issuing a temporary license. The temporary permit is issued for 90 days and may be extended OFFICE USE ONLY DDB R* V. T. CBC CCL EXPIRES Nursys Verification ID TYPE OF APPLICATION 1. Check type of application you are filing Registered Nurse I have a current active RN license in another jurisdiction state U*S* territory or District of Columbia. I have never held a Delaware RN license. Licensed Practical Nurse I hold a current active LPN license in another jurisdiction state U*S* territory Temporary Permit I have an offer of Nursing employment in Delaware and wish to start working before IDENTIFYING AND CONTACT INFORMATION 2. Full Name Last First Middle Maiden 3. Other Names Used 4. Date of Birth month/day/year Gender Male Female No If yes enter your SSN 5. Have you been issued a U*S* Social Security Number Yes If no you must file a Request for Exemption from Social Security Number Requirement. 6. Enter your State or Jurisdiction of Residence showing this jurisdiction as your residence. 7. Mailing Address City State Zip 8. Phone Email daytime evening or cell EDUCATION INFORMATION 9. Enter the following information about the high school you attended High School Name Address Year Entered Year Completed check one State/Country Zip/Postal Code I graduated from high school* Enter year I received a GED. Enter year 10. Did you graduate from nurse education program outside the United States Yes Number Certificate Date If yes enter CGFNS Name of Institution Conducting Nursing Program Entered Program Month/Year Graduated Month/Year Type of Program check one Baccalaureate Associate Diploma Practical Nurse Program Other Enter type of degree LICENSURE HISTORY In these questions jurisdiction means State District of Columbia U*S* territory or other country. If yes 12. Have you ever applied to take an examination for RN or LPN licensure but were denied Yes when Explain why you were denied If yes where 14. In which state or jurisdiction were you originally licensed by examination License Number Year Issued 15. List all states and other jurisdictions in which you now hold or have ever held a Nursing license application process unless the jurisdiction is a compact state. 17. Are any of your Nursing licenses currently under investigation Yes If yes where 18. Have any of your Nursing licenses ever been disciplined including revocation suspension probation voluntary If yes If yes where Enclose surrender limitation or letter of reprimand Yes a copy of the legal documents. NURSING PRACTICE needed* RN or LPN RN LPN EMPLOYER ADDRESS city state EMPLOYMENT DATES From To 20. Which of the following describes your Nursing practice Check all that apply. I have practiced Nursing AT LEAST 1000 hours during the past five years. I have completed a Refresher Course in the past two years. Submit proof of course completion* skip to the DISCLOSURES section* None of the above describes my practice. Enclose a written explanation* CONTINUING EDUCATION Unless you graduated from a Nursing education program within the past two years you are required to complete Continuing Education before a Delaware license can be issued* 21. You must check one I am a Licensed Practical Nurse. I have completed 24 hours of continuing education CE in the past two years. I am a Registered Nurse. I have completed 30 hours of continuing education CE in the past two years. 22. List the CE you have completed in the past two years in the spaces provided below. Enter complete date month/day/year as shown on certificate. Enter the number of CE hours for each course and provide a total* If you need more room provide the same information on a separate sheet and enclose it with the application* COURSE DATE NAME OF COURSE/PROGRAM/CONFERENCE CE HOURS PROVIDER NAME TOTAL DISCLOSURES misdemeanor or any other criminal offense including any offense for which you have received a pardon in any If yes explain jurisdiction Yes Arrange for the Board office to receive a criminal background check following the instructions on the Authorization for Release of Information form* 24. Are criminal charges pending against you in any jurisdiction Yes If yes explain below and enclose copies of any legal documents 25. Are you now or have you ever been dependent on the use of alcohol stimulants or habit-forming drugs Yes DUTY TO REPORT 26. To obtain a license in Delaware you must certify that you understand that you have a mandatory obligation to file a written report with the Board of Medical Licensure and Discipline within 30 days if you have any reason to believe that a medical practitioner other than yourself is or may be guilty of unprofessional conduct as defined in 24 Del* C. 1731 OR that he/she is or may be medically incompetent mentally or physically unable to engage safely in the practice of medicine excessively using or abusing drugs including alcohol* I certify that I have read and understand the provisions of 24 Del* C. 1730 24 Del* C. 1731 and 24 Del* C. 1731A and that I understand my duty to report. Yes an immediate oral report to the Department of Services for Children Youth and Their Families if you know of or you suspect child abuse or neglect under Chapter 9 of Title 16 and to follow up with any requested written reports. Unsafe nursing practice to the Board of Nursing and to report any unsafe practice conditions to the recognized legal authorities. Understand my duty to report. Yes TEMPORARY LICENSURE Complete this section only if you have an offer of employment and plan to begin work before the endorsement process is completed* Delaware Temporary Permits are not valid for work in other States. Applicant Name PRINT Employer Anticipated Start Date Contact Name Employer Phone and results of the criminal background check before issuing a temporary permit. If Board review of your application is required the Board office must receive all of these items no later than 4 30 PM ten full working days before the Board s meeting date in order to assure consideration of your application at the meeting Completed signed and notarized application form Fee payment All required supporting documentation* Applications that are not complete within six months of filing may be considered abandoned and discarded* Please note When your application is complete please allow 4-8 weeks to receive your permanent license whether or not a temporary license has been issued. AFFIDAVIT The law regulating the practice of Nursing in Delaware 24 Del* C. 1922 a Grounds for Discipline provides that the Board of Nursing may revoke or suspend any license to practice nursing refuse a license or re-licensing or otherwise discipline a licensee upon proof that a licensee or former licensee is guilty of fraud or deceit in procuring or attempting to procure a license to practice nursing* The applicant being duly sworn says that he/she is the person referred to in the foregoing application for licensure as registered/licensed practical nurse in the State of Delaware that he/she meets the requirements for licensure that the statements therein contained are true and that he/she has read and understands this affidavit. APPLICANT SIGNATURE Date County of State of Sworn to before me and subscribed in my presence this day of 2 Notary Public SEAL My commission expires APPLICATIONS THAT ARE UNSIGNED NOT NOTARIZED INCOMPLETE OR SUBMITTED WITHOUT THE REQUIRED PROCESSING FEE WILL BE REJECTED. Instructions for Requesting a Criminal Background Check Both state and federal criminal background checks are required* Locations Kent County Primary Facility State Bureau of Identification Blue Hen Mall Corporate Center 655 Bay Rd. Suite 1B Dover DE 19901 Walk-ins accepted Mon 9 am 7 pm Tue - Fri 9 am 3 pm Customer Service 302 739-2134 New Castle County - Satellite Facility State Police Troop Two 100 LaGrange Ave Newark DE 19702 Between Rts. 72 and 896 on Rt. 40 By appointment only Scheduling 302 739-2528 local 800 464-4357 toll free Sussex County Satellite Facility Delaware State Police Troop Four South DuPont Hwy Shortley Rd. Georgetown DE 19947 Across from DelDOT the State Service Ctr* Applicants Residing in Delaware 1. If you are using the New Castle or Sussex Counties locations call 800 464-HELP 4357 to schedule an appointment. No appointments are needed at the Kent County location* 2. Take the completed Authorization for Release of Information form to one of the offices listed above with the fee of 69. 00 to cover both the State and Federal criminal checks. Money orders and credit cards other than American Express are accepted at all locations. New Castle and Kent Counties accept cash Sussex County does not accept cash. Personal checks are not accepted in any county. As fees are subject to change contact the agency where you plan to submit your forms for current fees. Out-of-State Applicants 1. You can be fingerprinted by your local police agency. All types of fingerprint cards are accepted* If your local police agency cannot provide a fingerprint card call 302 739-2134 to request a fingerprint card. 2. Your Authorization for Release of Information form and fingerprint card must be complete. If identifying information is missing such as name date of birth race sex etc* your form will be returned* 3. Mail the Authorization form fingerprint card and certified check or money order personal checks are not accepted for 69. 00 made payable to Delaware State Police to PO Box 430 ALLOW FOUR WEEKS FOR RECEIPT OF RESULTS* DO NOT SEND THE FORM OR FEE TO THE BOARD OFFICE CRIMINAL HISTORY RECORD CHECK FOR PROFESSIONAL LICENSURE APPLICANTS AUTHORIZATION FOR RELEASE OF INFORMATION Please print or type all information in black ink. CHECK TYPE OF LICENSURE FOR WHICH APPLYING Adult Entertainment Medical Physicians Physician Assistants Respiratory Care Practitioners Acupuncture Practitioners Genetic Counselors Pharmacy Deadly Weapons Dealer Mental Health LPCMH LCDP LMFT LAPCMH LAMFT Psychology Dental Nursing RN LPN APN Social Work Massage Therapist Technician Nursing Home Administrator Texas Hold em Individual ENTER FULL CURRENT NAME Last Name First Name Middle Initial Suffix e*g* Jr. Sr. ENTER ALL OTHER NAMES USED IN THE PAST including but not limited to maiden name former married names alternative spellings As an applicant I authorize release of any and all information that you have concerning my CRIMINAL HISTORY RECORD INFORMATION* I hereby release you your organization the State of Delaware and others from any liability or damage which may result from furnishing this information SIGNATURE OF PERSON PRINTED Date Phone Home Work MAIL THE RESULTS OF MY CRIMINAL HISTORY REQUEST TO Division of Professional Regulation 861 Silver Lake Boulevard Suite 203 SLC D420A USE OF CRIMINAL HISTORY RECORD INFORMATION IS RESTRICTED BY LAW AND SHALL BE LIMITED TO THE PURPOSE FOR WHICH IT WAS GIVEN* MISUSE CONSTITUTES A CRIMINAL VIOLATION* EMPLOYER REFERENCE FORM FOR NURSING LICENSURE PURPOSES SECTION A APPLICANT INFORMATION to be completed by applicant Complete Section A and send to each nursing employer during the most recent six months of your nursing practice. If you graduated within the past year and have not been employed as a nurse for at least six months send this form to your school of nursing for completion in addition to sending it to your employers. You may duplicate the form as needed* Street 3. Social Security Number 5. Type of Application APN 6. Employer/School Name information about my Nursing employment and about my Nursing education at the above named institution* Forms returned by the applicant will not be accepted* Faxed forms will not be accepted* SECTION B REFERENCE to be completed by applicant s nursing employer or nursing school The applicant whose name appears on reverse has applied for Nursing licensure in Delaware. Please complete the appropriate box below and sign where indicated* Thank you for your assistance. NURSING EMPLOYER Name of Employer Month/Day/Year Based on this person s performance would you recommend her/him for licensure Yes If you checked no please explain* Your answer is a factor in determining eligibility for Delaware licensure. Name of Person Completing Form Title Signature Date OR NURSING SCHOOL educational program at Name of School Graduation Date Cannon Building Suite 203 VERIFICATION OF ORIGINAL LICENSURE Use this form only if the state or other jurisdiction where you were originally licensed by examination is not listed below. If Louisiana- Registered Nurse Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia-Practical Nurse Wisconsin Wyoming Mail form to jurisdiction where you were originally licensed by examination* Find out if the jurisdiction requires a fee before mailing. 1. State/Jurisdiction Where Originally Licensed 2. License Number 3. Name If originally licensed under another name enclose copy of legal document showing name change. SECTION B ORIGINAL LICENSURE VERIFICATION to be completed by Board of Nursing in jurisdiction of original licensure return to Delaware Board of Nursing at address above Name of Nursing School Board-Approved Yes Location Year Graduated Program AD BSN PN High School Graduate or GED Yes NCLEX/CAT Series Date Pass SBTPE Series Date Med OB Surg Peds PSV Date of Original Licensure License Number Expiration Date Currently licensed Yes Has license ever been disciplined Yes If yes enclose copy of decision order for each action* Board Representative Signature Title Date BOARD SEAL.