Cna Renewal Application - Nevada State Board Of Nursing Page 2
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3Section 3. Eligibility Screening Questions
If you answer “Yes” to any of Questions 1 through 6 below, you must attach a written explanation.)
(
1. Since your previous Nevada license/certificate was issued, has your application, or your license,
Yes
No
registration, certificate, or privilege to practice in any jurisdiction, of any level (does not include driver's
license or car registration):
a.
Been denied or disciplined by a regulatory Board including but not limited to reprimanded,
censured, fined, suspended, revoked, surrendered, limited or restricted, or placed on
probation or monitoring?
b.
Been subject to a non-disciplinary probation or monitoring program? AND/OR
c.
Is your license the subject of a current investigation, inquiry, pending settlement or hearing
in any state or jurisdiction?
If any answer is Yes, you must submit the following:
1.
A detailed letter of explanation that includes the state or jurisdiction where the action
occurred or is pending; and
2.
Copies of documents from the state or jurisdiction where there has been action, current
investigation, or inquiry.
2. Since your previous Nevada license/certificate was issued, have you had a criminal conviction, including
Yes
No
a misdemeanor or felony, or had a civil judgment rendered against you?
If the answer is Yes, you must submit the following:
a. A detailed letter of explanation including the events leading to your conviction; and
b. Copies of court documents, including the actual conviction, sentence, and current status of
sentence (i.e. all fines paid in full, completion letter from Parole or Probation Officer, etc.).
3. Do you currently use chemical substances in any way which impairs or limits your ability to practice the
Yes
No
full scope of nursing?
If the answer is Yes, you must submit:
a.
A letter of explanation that addresses the impairment or limitations of practice; and
b.
If you are using the chemical substance as a confirmed medical necessity, a letter from your
treating practitioner documenting the diagnosis and medical necessity for the use of
chemical substances, including any practice limitations.
4. Are you currently in recovery for chemical dependency, chemical abuse or addiction?
Yes
No
If the answer is Yes, you must submit:
a.
A letter of explanation describing your recovery experience, including length of continuous
recovery, treatment, current recovery activities, and relapse prevention plan;
b.
Documentation from knowledgeable individual(s) documenting your length of sobriety; and
c.
Documentation of a substance use evaluation, and inpatient or outpatient chemical
dependency treatment (if applicable).
5. Do you currently have a medical or psychiatric/mental health condition which in any way impairs or limits
Yes
No
your ability to practice the full scope of nursing?
If the answer is Yes, you must submit:
a.
A letter of explanation regarding your condition, whether temporary or permanent, including
diagnosis, past hospitalizations, date of last treatment, current treatment plan, and how your
condition may interfere with your ability to practice the full scope of nursing safely; and
b.
Documentation from treating practitioner regarding the diagnosis, (Axis I-V for psychiatric
diagnosis), medications, current status and treatment plan, the extent of condition, and
statement regarding your ability to carry out nursing duties reliably and with good judgment.
6. Since your previous Nevada license/certificate was issued have you had a malpractice judgment or
Yes
No
settlement entered against you, or do you have any pending malpractice suits or claims filed against
you?
If the answer is Yes, you must submit:
1. A detailed letter of explanation regarding the events leading to the suit; and
2. A copy of the complaint and current status of the case.
(continued)
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