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Reinstatement Application - Wyoming State Board of Nursing

Reinstatement Application - Wyoming State Board of Nursing

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COMPLETE THIS APPLICATION ONLY IF YOU ARE APPLYING FOR REINSTATEMENT OF YOURWYOMING LICENSE OR CERTIFICATION1) Personal Information:Registered Nurse <strong>Reinstatement</strong> Licensed Practical Nurse <strong>Reinstatement</strong> Certified <strong>Nursing</strong> AssistantSocial Security Number___________________________ Date <strong>of</strong> Birth______________ License #__________________Last Name_________________ First Name_________________ Middle Name__________ Maiden Name_____________Mailing Address________________________________________ City__________________ <strong>State</strong>_____ Zip__________Phone_______________________ Work Phone____________________ E-mail Address___________________________2) I meet continued competency requirements by ONE <strong>of</strong> the following:I worked a minimum <strong>of</strong> 500 hours as a RN/LPN in the last two (2) yearsI worked a minimum <strong>of</strong> 1600 hours as a RN/LPN in the last five (5) yearsI completed twenty (20) hours <strong>of</strong> RN/LPN continuing education in the last two (2) years(submit pro<strong>of</strong>—<strong>of</strong>ficial certificates or transcripts)I completed a RN/LPN refresher course in the last five (5) years(submit pro<strong>of</strong>—<strong>of</strong>ficial certificates or transcripts)I obtained certification in a specialty area <strong>of</strong> nursing practice by a nationally recognized accrediting agency acceptedby the board in the last five (5) years (submit verification <strong>of</strong> national certification)I passed the NCLEX-RN/PN within the last five (5) yearsI have worked a minimum <strong>of</strong> 16 hours as a CNA and have completed twenty-four (24) hours <strong>of</strong> 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 <strong>of</strong> support <strong>of</strong> reinstatement,a. Letters <strong>of</strong> support for reinstatement (such as from a sponsor, supervisor, work site monitor, counselor, ortherapist stating they are in support <strong>of</strong> the reinstatement.)b. <strong>State</strong>ment from the Nurse Monitoring Program (if applicable)c. Pro<strong>of</strong> that all conditions <strong>of</strong> 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 <strong>of</strong> 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 <strong>of</strong> 7APPLICATION FOR REINSTATEMENT <strong>of</strong> WYOMING NURSE LICENSURE or CERTIFICATION

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