Tpapn Referral Form - Texas Nurses Association

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TPAPN REFERRAL DOCUMENTATION
T EXA S
Complete all fields and PRINT this form.
PEER ASSISTANCE
PROGRAM FOR NURSES
INFORMATION ABOUT PERSON REFERRING NURSE
First Name
Last Name
Title
Place of Employment
Facility Address
City
TX
ZIP
Telephone
EMAIL
Relationship to Nurse
Colleague
Other
INFORMATION ABOUT NURSE BEING REFERRED
First Name
Last Name
Phone
Home Address
City
TX ZIP
Texas Nursing License Number
Expiration Date
SS#
LVN
Title
APRN License #
FEMALE
Age
Date of Birth
Job Status When Referred
Length of Employment
Type of Employment
Employed
Facility Name
[same as above]
[if different]
Current Area of Practice
Reason for Referral
Select
REQUIRED: Description of Possible Practice Violations. (
)
be specific, add additional pages as needed, click in box to start
Form Completed By
Date
Contact TPAPN at 1.800.288.5528 for any questions regarding making a referral.
Print form and FAX to (512) 467-2620 or mail to:
TPAPN, C/o Texas Nurses Foundation, 8501 N. MoPac Expy., Ste. 400, Austin, Texas 78759.
Please include supportive documentation, i.e., drug test results, etc.
Third party referral sources are also required to fax a copy to the Board of Nursing at (512) 305-7401.
Click here for the Texas Board of Nursing complaint form or go to Texas Board of Nursing.

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