Reinstatement Application - Wyoming State Board of Nursing

APPLICATION FORREINSTATEMENT ofWYOMING NURSE LICENSURE or CERTIFICATION*All licenses expire December 31 of every EVEN year*This is a Legal Document. By completing and signing this you certify underpenalty of perjury and subject to the provisions of Wyo. Stat. § 6-5-303, and its penalties, that you have notknowingly submitted false or misleading information to the Wyoming State Board of Nursing on anyapplication for licensure or certification.INSTRUCTIONS AND GENERAL INFORMATION: (Keep a copy for your records)Thank you for applying to the Wyoming State Board of Nursing (WSBN) for reinstatement. In order to processyour application quickly, please follow these instructions. Contact our office with any questions. We will behappy to assist you!Complete Application. If you choose not to type in the document, please print neatly in INK.You must provide all required information or your application will be considered incomplete. WSBNwill hold incomplete applications for one year from the date received.For faster notification of your application status, provide an accurate e-mail address.Provide payment of appropriate fees (by money order, cashier’s check, VISA, MasterCard or Discover).There are no refunds for incomplete or withdrawn applications.WSBN is paperless. All licenses, certificates & temporary permits will be available for verificationon-line at http://nursing.state.wy.us/.Requirements for Reinstatement:Chapter 2, Section 16. Reinstatement of Certification, Recognition and/or Licensure whose certificate has beensurrendered, conditioned, revoked or suspended may apply for reinstatement.The applicant shall:(i) Submit evidence of meeting the requirements established by the board's previous order;(ii) Submit evidence that just cause for reinstatement has been demonstrated;(iii) Submit the application and fee for reinstatement to the board as specified under Chapter V:Please Remember: WSBN’s primary purpose in consideration of any application for reinstatement, especiallyin light of prior disciplinary action taken against your license is that you are adequately competent to practice asa nurse or nursing and that there are no circumstances that otherwise suggest that there is a risk to the publichealth, safety and welfare. Such circumstances will affect how soon an investigation may be completed. Yourcooperation is greatly appreciated!RN $135.00; LPN $120.00Page 1 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

What you need to get started: (Check off items as you complete them)___ A form of payment WSBN accepts (money order, cashier’s check, VISA, MasterCard or Discover, page 3).___ A copy of documentation that you meet at least one (1) of the required continued competencies options (page 4).____ A copy of documentation of meeting requirements of a prior WSBN order, if applicable (such as particularrequirements indicated for reinstatement, compliance with conditions or other terms).____ A copy of documentation of meeting the “good cause” requirement (such as any information that supports yourreturn to nursing or nursing assistant practice; for example: professional letters of recommendations or support, additionalactivities outside of requirements of the prior WSBN order, or opportunities to gain employment if reinstated).Additional submissions (if requested)____ Fingerprint cards. If you have disclosed a pending criminal matter or a criminal conviction since your license wassurrendered, conditioned, revoked or suspended, the WSBN may request that you submit to a criminal background checkbefore we can issue a license or certificate. If a criminal background check is requested you will be contacted about thesubmission of fingerprint cards and applicable fees. Fingerprint cards will then be sent to you. Once you receive thefingerprint cards, provide completed fingerprint cards, following the instructions for chain of custody, and return toWSBN. You must return the completed fingerprint cards, applicable fee, and WSBN must receive the backgroundcheck report from the reporting agency before your license or certificate will be issued.If you would like your fingerprint cards mailed to a different address than what is listed on your application, pleaseprovide a self-addressed envelope (8” X 11”)._____ Mental/Physical Examination. If you have disclosed a mental or physical disability, or the existence of anaddiction (including treatment) since your license was surrendered, conditioned, revoked or suspended, the WSBN mayrequest that you submit to a biophysical, psychological, psychiatric, substance abuse, anger management, or competencyevaluation to confirm your ability to provide safe practice to the public before we can issue a license or certificate. Youwill be responsible for the costs of such evaluations.Changes in contact informationPlease advise us of any changes in the address, telephone or email information you submit with your application. If youdo not do so, it may delay the issuance of your license or certificate.Page 2 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

FEES(All fees are non-refundable and subject to change)You must include payment with your application; we accept CASHIER’S CHECK, MONEY ORDER, VISA,MASTERCARD OR DISCOVER.Name of Applicant (PLEASE PRINT):WSBN CANNOT ACCEPT PERSONAL CHECKS OR CASH.Cost Amount RN Reinstatement Fee $ 135.00 $ LPN Reinstatement Fee $ 120.00 $ Other $ $ Processing fee if paying by VISA, MasterCard or Discover (automatically assessed) $ 5.00 $ 5.00TOTAL amount due: $Name, Address, and Phone Number of Individual Paying (PLEASE PRINT): Licensee Paying Third Party PayingVisaMasterCardDiscoverNOTE: Depending onoffice volume, requestscould take up to 14business days toprocess, providingapplication/request isCOMPLETE.Card Number and Three Digit Security Code (on back of card):Security Code:- - -Expiration Date:By signing below, I authorize the Board of Nursing to debit my credit card for the total amount indicated above.Signature:__________________________________________________________________ Date:_______________Please help us to provide you with speedy customer service; review your application one more time to makesure you have submitted all the required documents and correct payment amount.RETURN YOUR COMPLETE APPLICATION AND PAYMENT TO:Wyoming State Board of Nursing130 Hobbs Avenue – Suite BCheyenne, WY 82002Page 3 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

COMPLETE THIS APPLICATION ONLY IF YOU ARE APPLYING FOR REINSTATEMENT OF YOURWYOMING LICENSE OR CERTIFICATION1) Personal Information:Registered Nurse Reinstatement Licensed Practical Nurse Reinstatement Certified Nursing AssistantSocial Security Number___________________________ Date of Birth______________ License #__________________Last Name_________________ First Name_________________ Middle Name__________ Maiden Name_____________Mailing Address________________________________________ City__________________ State_____ Zip__________Phone_______________________ Work Phone____________________ E-mail Address___________________________2) I meet continued competency requirements by ONE of the following:I worked a minimum of 500 hours as a RN/LPN in the last two (2) yearsI worked a minimum of 1600 hours as a RN/LPN in the last five (5) yearsI completed twenty (20) hours of RN/LPN continuing education in the last two (2) years(submit proof—official certificates or transcripts)I completed a RN/LPN refresher course in the last five (5) years(submit proof—official certificates or transcripts)I obtained certification in a specialty area of nursing practice by a nationally recognized accrediting agency acceptedby the board in the last five (5) years (submit verification of national certification)I passed the NCLEX-RN/PN within the last five (5) yearsI have worked a minimum of 16 hours as a CNA and have completed twenty-four (24) hours of learning activitiesrelated to CNA practice, (such as in-services or continuing education hours) in the last two (2) years..I completed a board-approved nursing assistant training and competency evaluation program AND passed a nationalnursing assistant certifying examination within the last two (2) years.I am currently enrolled in an approved nursing program and have participated in direct patient care.3) Required Information:Please submit the following information with your application.1. Evidence of support of reinstatement,a. Letters of support for reinstatement (such as from a sponsor, supervisor, work site monitor, counselor, ortherapist stating they are in support of the reinstatement.)b. Statement from the Nurse Monitoring Program (if applicable)c. Proof that all conditions of prior WSBN order have been met (if applicable).2. Appropriate evaluations (such as biophysical, psychological, psychiatric, substance abuse, angermanagement, competency evaluation), which should include a determination of fitness for duty or practice.3. Formal written letter to the board requesting reinstatement and why you feel you should be reinstated, (i.e.successfully completed monitoring program, etc.)4) Employment:Page 4 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

FIVE YEAR EMPLOYMENT HISTORY, STARTING WITH CURRENT OR MOST RECENTEmployment information must be complete. Attach a separate sheet if necessary.Include dates of unemployment, travel, school, homemaker, etc. Do not leave any period of time unaccounted for orthe application will be returned to you for completion.If employed as a traveling nurse, indicate the individual agency from which you have or are acceptingassignments/employment.1. BEGINNING DATE ________________________ END DATE ________________________ HOURS PER WEEK_______MONTH/YEARMONTH/YEAREMPLOYER NAME ______________________________________________PHONE #______________________________ADDRESS_____________________________________ CITY_______________________ STATE__________ ZIP____________POSITION___________________________________ SUPERVISOR_________________________________________________2. BEGINNING DATE ________________________ END DATE ________________________ HOURS PER WEEK_______MONTH/YEARMONTH/YEAREMPLOYER NAME ______________________________________________PHONE #______________________________ADDRESS_____________________________________ CITY_______________________ STATE__________ ZIP____________POSITION___________________________________ SUPERVISOR_________________________________________________3. BEGINNING DATE ________________________ END DATE ________________________ HOURS PER WEEK_______MONTH/YEARMONTH/YEAREMPLOYER NAME ______________________________________________PHONE #______________________________ADDRESS_____________________________________ CITY_______________________ STATE__________ ZIP____________POSITION___________________________________ SUPERVISOR_________________________________________________IF YOU NEED MORE ROOM TO COMPLETE YOUR FIVE YEAR EMPLOYMENT HISTORY, PLEASE ATTACH ASEPARATE SHEETAre you currentlyemployed in nursing:If you are currently employed innursing check all that apply: No Full time Part time Retired Volunteer Acute Care (Hospital) Assisted Living Case/Disease Management Doctor’s Office Home Health Long Term Care(Nursing Home) Nursing Education Private Clinic Public Clinic Public Health School Nurse State Facility Student Telephonic Traveling Agency Unemployed Utilization Review Other:_____________________________________Page 5 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

5) History Information:Since the surrender, revocation or suspension of your license or certificate, or the issuanceof your conditional or restricted license or certificate, have you had any of the following?All questions must be answered by the applicant. If you fail to answer each and every question and provide necessarydocumentation for any “Yes” answer the processing of your reinstatement will be significantly delayed. Your application isINCOMPLETE until all required documentation is received.1. Has any disciplinary action been taken or is pending (i.e. open investigation) against you from a LICENSINGAUTHORITY? No Yes If “YES”, provide: • Personal Statement •Documentation of disciplinary action2. Have you been investigated or charged with ABUSE, NEGLECT OR MISAPPROPRIATION OF PROPERTY? No Yes If “YES”, provide: •Personal Statement • Documentation of disciplinary action3. Has your application for examination or licensure ever been DENIED BY A LICENSING AUTHORITY? No Yes If “YES”, provide: •Personal Statement •Documentation of the denial action4. Do you have a physical or mental disability which renders you unable to perform nursing services or duties withreasonable skill and safety and which may endanger the health and safety of persons under your care? No Yes If “Yes”, provide: • Personal Statement • Progress report from counselor/physician • Dischargesummary/aftercare plan from hospitalizations (IF you were hospitalized)5. Have you had any relapses with drugs and/or alcohol since you were issued a conditional license? No Yes If “Yes”, provide: • Personal Statement • Progress report from counselor/physician • Dischargesummary/aftercare plan from hospitalizations (IF you were hospitalized)6. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care positionbecause of your use of alcohol or use of any controlled substance, habit-forming drug, prescription medication, ordrugs having similar effects? No Yes If “Yes”, provide: • Personal Statement • Progress report from counselor/physician • Dischargesummary/aftercare plan from hospitalizations (IF you were hospitalized)7. Have you been arrested, convicted, pled guilty to, pled nolo contendere to, received a deferment, or have chargespending against you for any crime including felonies, misdemeanors, municipal ordinances, and/or any militarycode of justice violations, including driving under the influence of any intoxicating substance? Do not includenon-moving traffic violations or moving violations which did not involve alcohol or substance impairment. No Yes If “YES”, provide a Personal Statement and court documents including:•Information Sheet or Ticket•Judgment and Sentencing•Proof of compliance with the following (if applicable):o Court Order o Fines Paido Probation Completion o Classes Attendedo Evaluation Completed and Subsequent Actionon that Evaluationo Proof that the case is closedSIGNATURE REQUIRED: I certify under penalty of perjury and subject to the provisions of W.S. 6-5-303 and itspenalties, that I have not knowingly submitted false or misleading information to the Wyoming State Board ofNursing on any application for licensure or temporary permit. I understand the WSBN reserves the right to verifyany information in this application.Applicant’s Signature: ____________________________________________Date: __________________Page 6 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION

Please help us to provide you with speedy customer service; review your application one more time to make sure you have submitted allthe required documents and correct payment amount. Thank you for applying for a Reinstatement.General Information:Every application is reviewed on an individual basis.The Disciplinary Committee (DC) performs the investigation & assembles materials/information to send to Board. Membersof the WSBN review all materials, ask for more information if needed and make the decision.Wyoming Law does not have a time limit on disclosures of past convictions.Fingerprints / Background Check reveal: (if applicable)‣ All charges in all states regardless of your age at time of offense‣ Any charges (even charges you were told were dismissed or expunged)The WSBN considers the following:‣ Passage of time – how recent the crime(s) took place;‣ Repeated, habitual crimes;‣ Felony versus misdemeanor (although the nature of the crime is a primary consideration);‣ Compliance with the court orders (probation, payment of fines, attendance at anger management or driving classes,evaluations, etc.);‣ Results/recommendations of existing or requested evaluations (e.g., psychological, psychiatric, substance abuseevaluations, anger management, competency evaluations, etc.); and‣ How the crime relates to nursing practice and public safety (for example, a history of domestic violence may beconsidered a risk for harming a vulnerable patient).All requirements imposed from discipline from other State Boards of Nursing against your license/certification must becompleted before applying to WSBN.It takes a significantly longer period of time to process your application if you have disclosed a discipline/compliance issue. Ittakes even longer if you have failed to disclose and the issue is revealed through your criminal background check.Court Documents: The WSBN requires all court documents from the beginning of the arrest to the final disposition of your case, even if thecharge(s) was pled down to a lesser charge, deferred, dismissed, etc. Failing to provide complete documentation only delaysthe process. The WSBN requires the following court documents:‣ Charging document; sometimes called the information sheet;‣ Judgment and Sentencing;‣ Proof and compliance with the court orders:1. Court fines were paid;2. Probation completed without problems; if you are currently on probation e-mail wsbn-infolicensing@wyo.govand provide your contact information, we will contact you to discuss yourindividual situation;3. Classes attended; and4. Evaluations completed and subsequent action on that evaluation.Personal Statement (a SIGNED statement in your own words): A good personal statement describes:o The month and year of the incident o Full description of the incidento Legal or court action taken against you o Treatment and outcome of treatment if applicable (i.e.mental health, substance abuse, etc.)o What you have learned o How you have changed, specifically, what changes have youmade in your behavior and decision-making as a result ofyour criminal pasto How you will assure the ARC that thistype of behavior will not happen againo Signature and DateDo not simply list out the charges; this will be rejected by the DC and cause significant delays and may result in the DC notgranting a certificate /license.Please visit the discipline tab on our website at: http://nursing.state.wy.us for an example of a personal statement that meetsthe elements required by the DC.Page 7 of 7APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION