Download NCLEX-RN Re-Take Application

Nursing
[email protected]
www.vtprofessionals.org
Vermont Secretary of State
Office of Professional Regulation
89 Main St., 3rd Floor
Montpelier VT 05620-3402
Vermont Board of Nursing
INSTRUCTION TO APPLICANTS
The following applies to applications received after 1/14/2015 requesting NCLEX testing:


If you have graduated from your initial nursing education program less than 5 years ago, you must pass the NCLEX
examination within 5 years of that graduation date.
If you have graduated from your initial nursing education program more than five years ago, you may take the NCLEX
examination through Vermont one time only. No exceptions.
NCLEX RN - RETAKE (International) – Applicant must submit the following:
1.
Complete Vermont Application.
2.
Application Fee of $30.00 (Non-Refundable Processing Fee)
3.
2x2 Photo (Passport sized photo of head and shoulders taken within the last 6 months other than your
driver’s license or passport)
4.
Copy of current passport or U.S. Identification
5.
Copy of current RN license
6.
Verification of Initial License (If applicable)
7.
Verification of most recent licensure (if applicable)
NOTES:


Any change of address or other contact information, by an applicant or licensee, must be forwarded to this office no later than
thirty (30) days after change occurs.
A Valid US Social Security number is mandatory.
Send completed form to:
Vermont Board of Nursing
Office of Professional Regulation
89 Main Street, 3rd Floor
Montpelier, VT 05620-3402
Vermont Secretary of State
Office of Professional Regulation
89 Main Street, 3rd Floor
Montpelier VT 05620-3402
Licensing Board Specialist
[email protected]
www.vtprofessionals.org
Vermont Board of Nursing
NCLEX-RN Retake Application -International
2x2 Recent Photo- Paste Here
Application Fee: $30.00 (non-refundable)
Office Use Only
Passport sized photo of head and
shoulders taken within the last 6
months.
(Use Ink or Typewritten only)
First Name (Legal name; no nicknames)
Middle
Last Name
Previous Name(s) (Maiden)
Social Security Number: ________/_______/__________**
(Providing your social security number (SSN) is mandatory, and requested under
the authority granted by 42 U.S.C. §405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, and the Department of Labor in the administration of Vermont
law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request);
Passport#________________________Country of Issuance:___________________Expiration Date:____________
Note: It is unprofessional conduct for a licensee to fail to notify the Secretary of State’s Office of a change of name or address within
thirty (30) days (3 V.S.A. § 129a(a)(14).
P.O. Box
Street/Apt #
Mailing Address:
City/State/Zip
Country
Box Street/Apt #
911 Address:
(if different than
mailing)
Suite/Department/Floor
City/State/Zip
Phone:
(
)
-
Work:
Cell Phone:
(
)
-
E-Mail:
Date of Birth
Gender: (Circle One)
Female
RN (International) Re-Take Application 2015 0115
Place of Birth (city, state, country)
Male
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Section B: Vermont Mandatory “Good Standing” Declarations
CHILD SUPPORT:
Child Support Orders, 15 V.S.A. § 795(b): “Good standing” for child support is defined by 15 V.S.A. § 795(d).
You must check the appropriate box. As of the date of this application:
I am not subject to a child support order.
I am subject to a child support order and I am in “good standing” or in full compliance with a plan to pay
any and all child support.
I am subject to a child support order and I am NOT in “good standing” or in full compliance with a plan to
pay any and all child support. Please contact the Office of Child Support at (802) 241-2319. OCS must report
your compliance to this office before you may be issued a license.
TAXES:
Taxes Due to the State of Vermont, 32 V.S.A. § 3113(b): “Good Standing” for taxes due is defined by 32 V.S.A.
§ 3113(g). You must check the appropriate box. As of the date of this application:
I am in “good standing” with respect to, or in full compliance with a plan to pay any and all taxes due to
the Vermont Department of Taxes.
I am NOT in “good standing”* with respect to or in full compliance with a plan to pay any and all taxes
due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) 8282515 for more information. The Tax Department must report your compliance to this office before you may
be issued a license.
DISTRICT COURT FINES/JUDICIAL BUREAU:
Court judgments for fines or penalties, 4 V.S.A. § 1110(b): “Good standing” for court judgments is defined by 4
V.S.A. § 1110(c). You must check the appropriate box. As of the date of this application:
I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines
or penalties for a violation or criminal offense.
I am in “good standing” with respect to any unpaid judgment issued by the judicial bureau or criminal
division of the superior court for fines or penalties for a violation or criminal offense.
I am NOT in “good standing” with respect to any unpaid judgment issued by the judicial bureau or
criminal division of the superior court for fines or penalties for a violation or criminal offense.
You must provide this office documentation of compliance before you may be issued a license.
RESTITUTION ORDERS:
Unpaid Judgments, 13 V.S.A. § 7043a: “Good standing” for restitution orders is defined by 13 V.S.A. §
7043a(c). You must check the appropriate box. As of the date of this application:
I have no restitution order.
I am in “good standing” with respect to any restitution order.
I am NOT in “good standing” with respect to any restitution order.
You must provide this office documentation of compliance before you may be issued a license.
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Section C: Vermont Mandatory Credential and Fitness Questions
Circle Yes or No for each of these questions. If the answer is Yes, follow the instructions provided.
Have you committed acts of abuse, neglect, or misappropriation of patient property?
If “Yes,” provide a detailed written explanation and attach all related documents.
Yes
No
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an
application by you for a license, certificate, or registration to practice a profession or occupation?
If “Yes,” you must attach a copy of the order or official notification of the action(s).
Yes
No
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) taken any
disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or
registration that you hold or held in any profession or occupation?
If “Yes,” you must provide a copy of the order or official notification of the action.
Yes
No
Have you ever surrendered a license, certificate or registration to a licensing authority in Vermont or
any other state, federal authority or other jurisdiction (US or elsewhere)?
If “Yes,” you must provide a detailed written explanation and copies of any applicable documentation.
Yes
No
Are you currently under investigation by a licensing authority in Vermont or any other state, federal
authority or other jurisdiction (US or elsewhere)?
If “Yes,” you must provide a detailed written explanation and a copy of any available information from
the licensing authority.
Yes
No
Yes
No
Yes
No
Have you EVER been convicted of a crime other than a minor traffic violation?
(Driving While Intoxicated and Driving Under the Influence are not “minor traffic violations.”)
If “Yes,” you must provide a detailed written explanation and attach the official court documents (i.e.,
affidavit of probable cause, the information and/or the docket report.)
Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)?
If ”Yes,” you must provide a detailed written explanation and attach a copy of the charging
documents.
Note:
Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any
conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. § 129a(a)(11).
The answers to the following questions are not subject to public disclosure:
Do you have a physical or mental condition or disorder which in any way impairs or limits your ability
to practice this profession with reasonable skill and safety?
If “Yes,” you must have your health care provider submit a detailed statement explaining how you
are able to practice safely.
Yes
No
Does your use of alcohol, substances, or prescription medications impair or limit your ability to
practice this profession with reasonable skill and safety?
If “Yes,” you must provide a detailed written explanation.
Yes
No
Yes
No
Yes
No
Are you currently addicted to or in any way dependent on alcohol or habit forming drugs?
If “Yes,” you must provide a detailed written explanation.
Are you currently participating in a supervised program or professional assistance program which
monitors you in order to assure that you are not engaging in the use of alcohol or controlled
substances?
If “Yes,” please provide the contract/stipulation under which you are practicing.
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Number of times you have taken the NCLEX:____________________________
Dates Taken: _____________ ______________
Month/Year
Month/Year
_____________
Month/Year
____________
Month/Year
_____________
Month/Year
Vermont State Board of Nursing
Practice Requirement
PLEASE PRINT CLEARLY
I have graduated from my nursing education program within the last five (5) years:
Yes______ No _______
Date of Graduation: ______________________ Name of Nursing Program _______________________________
(MM/DD/YYYY)
I have practiced as a registered nurse as defined in (26 V.S.A. §1576(c); Rules Part 6.8 (g), for at least (check the
appropriate statement):
__________120 days (960 hours) in the last 5 years
or
__________ 50 days (400 hours) in the last 2 years
__________ I have not worked as a registered nurse in the last 2 or 5 years.
If you have not worked as a registered nurse as above you may not be eligible to retake the NCLEX RN
Examination through Vermont.
Position # 1 (most recent)
Name of Employer: ______________________________________ Telephone Number (____) ____________
Employers
Mailing Address:__________________________________________________________________________
(Street/PO Box)
________________________________________________________________________________________
(City)
(State)
(Country)
(Zip/Postal Code)
Supervisor’s Name _____________________________________ Title: ______________________________
Supervisor’s Telephone Number (____) ________________ Email address: ___________________________
Job Title: ____________________________________________ Paid or Volunteer_____________________
Full Time or Part Time: _________________________________
Dates of Employment: From_____________________________ To__________________________________
(MM/DD/YYYY)
(MM/DD/YYYY)
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Vermont State Board of Nursing
Practice Requirement Form
PLEASE PRINT CLEARLY
Position # 2
Name of Employer: ______________________________________ Telephone Number (____) ____________
Employers
Mailing Address:__________________________________________________________________________
(Street/PO Box)
________________________________________________________________________________________
(City)
(State)
(Country)
(Zip/Postal Code)
Supervisor’s Name _____________________________________ Title: ______________________________
Supervisor’s Telephone Number (____) ________________ Email address: ___________________________
Job Title: ____________________________________________ Paid or Volunteer_____________________
Full Time or Part Time: _________________________________
Dates of Employment: From_____________________________ To__________________________________
(MM/DD/YYYY)
(MM/DD/YYYY)
3. If you practiced as a registered nurse in a private duty capacity or as a volunteer, attach:
Private Duty:
1. An Official letter from the Attending Physician on their letter head, stating that RN care was required.
The letter must clearly list the Physicians name, title, contact telephone number and have their signature.
2. A letter from your Employer or Client, verifying your role and duties as a Private Duty Nurse. They must verify
the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact
telephone number, email address, mailing address and have their signature.
Volunteer:
1. An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of
Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer Nurse, and a letter
listing the number of days, hours and dates worked. The letter must clearly list the name of the Director of
Nursing or Director of Human Resources, their telephone number, email address, mailing address and have
their signature.
Statement of Applicant
I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and
accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the
denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison
and/or a $10,000 fine. (13 V.S.A. §2901)
Signature of Applicant
Date
Vermont Board of Nursing
Office of Professional Regulation
89 Main Street, 3rd Floor
Montpelier, VT 05620-3402
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