Application for Reactivation of a Licence in Nova Scotia

Transcription

1 Please return the completed application to CRNNS at the address noted above with proof of legal name (if it has changed since last licensed with CRNNS). A. Personal Information Show given names in full. Surname Print in block letters First name Middle name Birth name Former name(s) of birth (M/D/Y) CRNNS Registration #: Applying to reactivate licensure as a: registered nurse nurse practitioner B. Nurse Registration/Licensure List all jurisdictions where you have been registered or licensed as a registered nurse, nurse practitioner, or other regulated professional since you were last licensed with the CRNNS. List the most recent province/country of licensure first: Province, State or Country Registration # Current Status (Active/Non-Active) Issued (Month/Year) Expired (Month/Year) C. Judicial Questions Answer the following questions based on your conduct both within and outside Canada: 1. Have you ever been charged with, pleaded guilty to, been convicted of or found to be guilty of an offence, for which you have not received a pardon, including alcohol and drug related offenses but excluding parking, speeding or similar minor motor vehicle offences that do not involve substance use? 2. Have you ever pleaded no contest or made any similar plea to any criminal charge? 3. Have you ever been charged with or accused of a criminal offence that resulted in you entering into a diversion program, curative discharge or other resolution process as an alternative to conviction or prosecution? 4. Has there ever been any civil proceeding, legal action, insurance or other claim that was in any way related to your practice of nursing or your professional activities which you have not previously reported to CRNNS? 5. Is there now, or are you aware of any pending civil proceedings, legal actions, insurance or other claims that are in any way related to your practice of nursing or your professional activities which you have not previously reported to CRNNS? 6. Have you ever agreed to a settlement as a means to resolve civil proceedings or in relation to any investigation, proceeding or disciplinary action with respect to your professional conduct, competence, character, capacity or fitness to practice which you have not previously reported to CRNNS?

2 7. Are you currently the subject of any complaint, investigation or other proceeding by any registration/licensing authority? 8. Have you ever, before or during the course of an investigation or disciplinary proceeding, voluntarily entered into an undertaking or otherwise agreed to restrict your practice or to refrain from practice? 9. Have you ever been disciplined by a registration/licensing authority for any occupation/profession? 10. Do you have any conditions or restrictions on any licence that you currently hold or have held in any occupation or profession? 11. Have you ever been denied or had revoked any occupational or professional registration, license or permit which you have not previously reported to CRNNS? 12. Were you ever the subject of an investigation, disciplined by or expelled from any university or school of nursing which you have not previously reported to CRNNS? 13. Have you ever been suspended or terminated from any employment which you have not previously reported to CRNNS? 14. In addition to the above, is there, to your knowledge or belief, any event, circumstance or condition concerning your competence, character, capacity, conduct or reputation that may impact your registration as a registered nurse? 15. For Nurse Practitioners Only: Do you have any Health Canada Notices (circular letters) related to prescribing controlled drugs and substances which you have not previously reported to CRNNS? IF ANSWERING YES TO QUESTIONS 1-15, PLEASE ATTACH AN EXPLANATION. D. Nursing Practice Licensure year last licensed with CRNNS: (Licensure year is from November 1 st to October 31 st ) Please record the total number of actual hours worked as a registered nurse and/or nurse practitioner from November 1 to October 31 for the current and previous five years. current year, to date of application one year previous two years previous three years previous four years previous Year (from November 1 to October 31) RN Hours NP Hours Have you taken a nursing re-entry program in the last five years? Yes No If yes, Name and Location of Program: Completed:

3 E. Nursing Experience Following Graduation Include all work experience since graduation (you may attach another page if needed). s of Immediate Supervisor Facility & Telephone Facility Name Facility Address Employment & Position Title # F. Current Address Street Address City/Town Province/State Postal Code Country address Telephone #

4 Signature Declaration By signing this application form: I authorize the collection, use and disclosure of personal information concerning myself as described in the College of Registered Nurses of Nova Scotia (CRNNS) Privacy of Member Information Policy. You can find this policy on the following webpage: In addition, I authorize CRNNS to carry out the procedures necessary for the assessment of my eligibility for licensure. This includes making copies of my application documents for the purpose of assessment and/or contacting the employers, institutions or authorities stated on this application to verify the authenticity of my documents and the information provided in my application. This Signature Declaration allows the CRNNS to contact other regulatory bodies and obtain information pertinent to my application. I agree that a copy of this Signature Declaration can be sent by CRNNS to other regulatory bodies allowing them to release information to CRNNS. I declare that all of the information I have provided in my application is complete and truthful. I understand that CRNNS will immediately stop the assessment of my application and that my application for assessment will be cancelled, licensure will be refused, and I may be prohibited from applying to CRNNS in the future if: 1. I have provided any inaccurate information; or 2. I have omitted required information; or 3. CRNNS determines that any documents submitted during the application or assessment process have been altered, tampered with or forged. This applies to all documents received during the application process, including verifications of registration and written correspondence. CRNNS will not issue a refund and will retain all documents submitted with my application. This Signature Declaration authorizes CRNNS to share with other Canadian regulatory bodies that my application for licensure has been refused because of one of the three reasons listed above. I understand that in order to practise nursing in Nova Scotia, I am required by law to hold a licence with CRNNS before I commence employment, including any orientation. I have read and understand the above and the information on this form and agree to the terms stated herein. Print Name Signature of Applicant Print Name of Witness Signature of Witness

5 Verification of Registered Nurse Registration for Reactivation of Licence Section A Applicant Complete Section A, forward the form to each registering/licensing authority where you have held registration/licensure since last licenced in Nova Scotia, requesting they verify your status by completing Section B. Name Surname Birth/Former Name(s) Given Names Address School of Nursing & Location Year of Graduation Year registered in original jurisdiction Reg # Signature Section B Registering Authority Please verify the registration/licence status of the person named above and return the completed form directly to the College of Registered Nurses of Nova Scotia at the address noted below. Acting on behalf of the_ Original Registering Authority I do hereby certify that Surname Birth/former Names Given Names A graduate of School of Nursing Location and that this school of nursing was approved by the registering authority at the time this program was completed. The original registration certificate/licence as a general registered nurse was issued by this jurisdiction on (Month/day/year) Registration/licence number: Registration was obtained by: examination endorsement Current registration status Expiry date of registration (Month/day/year) 1. Is this person currently under review/investigation by your regulatory body? 2. Has this person ever received any type or form of disciplinary action on his/her registration or licence in your jurisdiction such as revocation, suspension, or reprimand? YES YES (attach an explanation) (attach an explanation) 3. If you answered yes to #2, has the registration/licence been reinstated? YES (attach an explanation) 4. Has this person ever had any conditions or restrictions imposed on their licence? 5. If you answered yes to #4 above, conditions or restrictions imposed on their licence been removed? YES (attach an explanation) YES date reinstated: Position Signature Name (please print) SEAL Rev 04/15

6 Statement from Current/Most Recent Employer for Reactivation of Licence Section A Applicant to complete Section A and forward form to the Director of Nursing OR Director of Human Resources at your current/most recent place of employment requesting completion of Section B. This statement must be received from an employer with whom you have worked for a minimum of six (6) months. Name Surname Birth/former name(s) Given names Employee # Signature Telephone #/ address Section B Employer The above named applicant is applying for reactivation of licence with the College of Registered Nurses of Nova Scotia. Please complete the following statements in relation to the applicant's employment as a registered nurse and confirm that no professional, ethical and/or health problems have occurred to indicate a licence should not be issued. Please return the completed form to the CRNNS at the address noted below. A response by mail or is acceptable. No faxes please. Thank you for your assistance. This is to verify that was employed by Name of employee Name of organization between month/day/year Mailing address and month/day/year Employment Status (indicate one) Full time Part time Position Total Hours Practised Eligible for Re-Hire YES/ If, please attach an explanation. General Performance/Comments/Concerns Signature Name (please print) Telephone #/ address Position (please print)