APPLICATION FOR INACTIVE STATUS of a CONDITIONAL WYOMING NURSE LICENSURE or CERTIFICATION *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this form, you certify under penalty of perjury and subject to the provisions of Wyo. Stat. 6-5-303 and its penalties, that you have not knowingly submitted false or misleading information to the Wyoming State Board of Nursing on any application for licensure or temporary permit. INSTRUCTIONS AND GENERAL INFORMATION: (Keep a copy for your records) In order to process your application for inactive status of your conditional license or certificate in a timely manner, please follow these instructions. Contact our office with any questions. We will be happy to assist you! Complete application and pay the $35.00 fee. Please use INK. You must provide all required information or your application is incomplete. WSBN will hold incomplete applications for one year from the date received. For faster notification of your application status, provide an accurate e-mail address. There are no refunds for incomplete or withdrawn applications. Please be sure that all submitted attachments have your name on the document. WSBN is paperless. All licenses will be available for verification on-line at http://nursing.state.wy.us/. Inactive Status: Wyoming Nurse Practice Act 33-21-131 Licensees who hold an active license to practice in this state, and who wish to discontinue the practice of professional or practical nursing in this state, may request in writing that the board place their license on inactive status. A licensee on inactive status shall not be considered lapsed or expired. A biennial renewal fee shall be required to retain the inactive status. Licensees on inactive status may apply for reactivation pursuant to board rules and regulations. WSBN Rules and Regulations: Chapter 2 Section 13. Inactive Status. (a) A licensee who holds a current license and desires inactive status shall submit a written request to the board. (b) The board may allow a licensee to place his/her license on inactive status by submitting the following: (i) The completed application and fee for inactive licensure status; (ii) A signed statement attesting that the licensee has committed no acts which are grounds for disciplinary action as set forth in the Wyoming Nursing Practice Act, WS 33-21-146, or if an act has been committed, the board Page 1 of 5
(c) (d) has found after investigation that sufficient restitution has been made. (A) If sufficient restitution has not been made, the board may allow a licensee under investigation or with an encumbered license to place his/her license on inactive status under the following conditions: (I) At the time the licensee chooses to seek reactivation, the investigation will be continued and the complaint and investigative file will be forwarded to the board's disciplinary committee; or (II) At the time the licensee chooses to seek reactivation, the conditions of the Stipulation and Order will become activated; and (III) The probation period shall not end until the licensee has submitted evidence of compliance with the terms of the Order. A licensee shall be notified that transfer of the license to inactive status shall be effective on the date of the expiration of the current license. The licensee shall not practice nursing in this state until the license is reactivated. Personal Statement (a SIGNED statement in your own words): A good personal statement describes: The reason you are requesting to be placed on inactive status, and describes specifically how you are currently compliant with all aspects of your conditional license or certificate. General Information: It takes a significantly longer period of time to process your application if you have disclosed a discipline/compliance issue. It takes even longer if you have failed to disclose and the issue is revealed through your criminal background check. Court Documents: The Board requires all court documents from the beginning of the arrest to the final disposition of your case, even if the charge(s) was pled down to a lesser charge, deferred, dismissed, etc. Failing to provide complete documentation only delays the process. The BOARD 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 wsbninfo-licensing@wyo.gov and provide your contact information, we will contact you to discuss your individual situation; 3. Classes attended; and 4. Evaluations completed and subsequent action on that evaluation. Page 2 of 5
1) Personal Information: Social Security Number Date of Birth License/Certificate # Last Name First Name Middle Name Maiden Name Mailing Address City State Zip Phone Work Phone E-mail Address 2) Required Information: Please submit the following information with your application. 1. Formal written letter to the board requesting your license or certificate status be changed to inactive. Explain why you are requesting the status change and include an explanation outlining your compliance or non-compliance with the terms and requirements of your conditional license or certificate. 2. Statement from NMP regarding compliance with conditions of conditional license or certificate. 3) Employment: CURRENT OR MOST RECENT EMPLOYER BEGINNING DATE END DATE HOURS PER WEEK MONTH/YEAR MONTH/YEAR EMPLOYER NAME PHONE # ADDRESS CITY STATE ZIP POSITION SUPERVISOR Are you currently employed in nursing: No Full time Part time Retired Volunteer If you are currently employed in nursing check all that apply: 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 3 of 5
4) History Information: DURING THE TIME YOU HAD A CONDITIONAL 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 necessary documentation for any Yes answer, then the processing of your inactive status request will be significantly delayed. Your application is INCOMPLETE until all required documentation is received 1. Has any disciplinary action been taken or is pending (i.e. open investigation) against you from any LICENSING AUTHORITY? No Yes If YES, provide: Personal Statement Documentation of disciplinary action 2. Have you been investigated or charged with ABUSE, NEGLECT OR MISAPPROPRIATION OF PROPERTY? No Yes If YES, provide: Personal Statement Documentation of disciplinary action 3. 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 action 4. Do you have a physical or mental disability which renders you unable to perform nursing services or duties with reasonable 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 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 6. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care position because of your use of alcohol or use of any controlled substance, habit-forming drug, prescription medication, or drugs having similar effects? No Yes If YES, provide: Personal Statement Progress report from counselor/physician 7. Have you been arrested, convicted, pled guilty to, pled nolo contendere to, received a deferment, or have charges pending against you for any crime including felonies, misdemeanors, municipal ordinances, and/or any military code of justice violations, including driving under the influence of any intoxicating substance? Do not include non-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 Paid o Probation Completion o Classes Attended o Evaluation Completed and Subsequent Action on that Evaluation o Proof that the case is closed SIGNATURE REQUIRED: I certify under penalty of perjury and subject to the provisions of W.S. 6-5-303 and its penalties, that I have not knowingly submitted false or misleading information to the Wyoming State Board of Nursing on any application for licensure or temporary permit. I understand the WSBN reserves the right to verify any information in this application. Applicant s Signature: Date: Page 4 of 5
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 Inactive Status $ 30.00 $ Other $ $ Processing fee if paying by VISA, MasterCard or Discover (automatically assessed) $ 5.00 $ TOTAL amount due: Name, Address, and Phone Number of Individual Paying (PLEASE PRINT): Licensee Paying Third Party Paying Visa MasterCard Discover Card Number and Three Digit Security Code (on back of card): Security Code: - - - NOTE: Depending on office volume, requests could take up to 14 business days to process, providing application/request is COMPLETE. 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 make sure you have submitted all the required documents and correct payment amount. RETURN YOUR COMPLETE APPLICATION AND PAYMENT TO: Wyoming State Board of Nursing 130 Hobbs Avenue Suite B Cheyenne, WY 82002 Page 5 of 5