Forms

Consumers

Document Title
Customer Service Evaluation Form
Speaker Request Form

Applicants

General Applications
Document Title
Licensure by Examination Instructions and Supplemental Forms
Licensure by Examination (8-Year Retake) Fee Schedule and Instructions
Licensure by Endorsement Instructions and Supplemental Forms
Breakdown of International Nursing Educational Program
International Diploma Verification Form
International License Verification Form
Notification of Social Security Number Change
Request for Accommodation of Disabilities
Request for Transcript
Advanced Practice Applications
Document Title
Public Health Nurse Certificate Application Instructions and Supplemental Forms
Clinical Nurse Specialist (CNS) Certification Application Instructions and Supplemental Forms
Nurse Anesthetist (NA) Certification Application Instructions and Supplemental Forms
Nurse-Midwife (NM) Certification Application Instructions and Supplemental Forms
Nurse Practitioner (NP) Certification Application Instructions and Supplemental Forms
Psychiatric/Mental Health (P/MH) Nurse Application Instructions and Supplemental Forms
Nurse Midwife Furnishing Number Application Instructions and Supplemental Forms
Nurse Practitioner Furnishing Number Application Instructions and Supplemental Forms

Education

Document Title
Continuing Approval - Nursing Program
Instructions for Institutions Seeking Approval of New Prelicensure Registered Nursing Program
New School of Nursing - Feasibility Study Report
Request for Major Curriculum Revision

Licensees

Document Title
Active to Inactive License
Application for Reinstatement of a Lapsed License - 8-Year Renewal
Continuing Education Provider Initial Renewal Notice
Notification of Social Security Number Change
Renewal Fingerprint Question Certification
Request for Duplicate Certificate

Enforcement

Document Title
Complaint
Expert Practice Consultant Application
Health Facility Reporting Form (805 Report)
Report of Settlement, Judgment, or Arbitration Award

Probation

Document Title
BRNPROB100 - AA-NSG Calendar BRNPROB116 - Rehabilitation - Treatment Form
BRNPROB101 - RN WPE BRNPROB117 - Cost Recovery - Payment Plan
BRNPROB102 - NP WPE BRNPROB118 - Data Form
BRNPROB103 - CRNA WPE BRNPROB119 - EDD Authorization for Release
BRNPROB105 - Tolled Update Form BRNPROB120 - Refresher Course and Clinical Approval Form
BRNPROB106 - Tolled - Request to Go into Tolled Status BRNPROB122 - Relapse Prevention Plan
BRNPROB107 - Confidential Release Form BRNPROB123 - Rule Out Examination Addendum
BRNPROB108 - Physical Examination Form BRNPROB124 - NSGF Confidential Release
BRNPROB109 - Therapy Form BRNPROB426 - Employer Agreement and Attestation
BRNPROB110 - NSG Facilitator Form BRNPROB427 - Worksite Monitor Agreement and Attestation
BRNPROB111 - Psychotropic Mood Altering Form BRNPROB428 - Home Health - Employer Agreement and Attestation
BRNPROB112 - Mental Examination Form BRNPROB429 - Home Health - Worksite Monitor Agreement and Attestation
BRNPROB113 - Employment Approval Form BRNDECAPP-01 - Process for Filing Petition
BRNPROB114 - Fingerprint Instructions and Form BRNDECAPP-05 - Petition for Early Termination of Probation
BRNPROB115 - First Source Enrollment Instructions BRNDECAPP-06 - Petition for Modification of Probation

Intervention

Document Title
Application for Nurse Support Group Facilitator/Co-Facilitator
Intervention Evaluation Committee (IEC) Application