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 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
Page 1 and 2: APPLICATION FORREINSTATEMENT ofWYOM
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Reinstatement Application - Wyoming State Board of Nursing

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