Multi-State Licensure Privilege Notification Form - South Carolina Department Of Labor, Board Of Nursing Page 2

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2. What is your practice status in SC? (Complete one section only)
Employed in nursing as defined in §40-33-20
(Includes direct patient care, teaching, counseling, administration
research, consultation, supervision, delegation, & practice evaluation)
,
Full Time in SC
Part time in SC
Private Duty in S.C.
01
02
13
18
Out of State, Specify State or Country__________
3. Indicate your current primary field/setting of employment in SC. (Mark only one)
GENERAL PATIENT CARE
OTHER SETTINGS
Hospital-Inpatient
Physician’s Office
26
07
Hospital-Outpatient
Other Office, Specify _______________________________
27
11
Hospital Wide (Exclude Codes 16 & 17 below)
Free-Standing Outpatient Clinic
28
21
(e.g. emergency, surgery, dialysis)
Nursing Home (Exclude Codes 18 & 19 below)
Health Department
02
08
Private Home Health Agency
23
Hospice
25
Faith Comm (Parish) Nurse
PSYCHIATRIC/MENTAL HEALTH
30
Hospital
Other Community Health, Specify Agency ______________
16
12
Nursing Care Facility
Occupational Health Nursing
19
06
Mental Health Center
School Nurse
13
05
Alcohol/Drug Detoxification Ctr or Halfway House
School of Nursing
20
03
Supplemental Staffing Agency
MENTAL RETARDATION
24
Hospital Unit of Mental Retardation Center
Self-Employed other than private duty (independent nurse)
17
09
Residential Care Facility (
Private Duty
18
Skilled, ICF, Other)
04
Non-Residential Care Facility
Insurer/Third Party Payer
22
29
(e.g. Non-Skilled Day Care, Sheltered Workshop)
Other, Specify __________________________________
10
4. Indicate your present major clinical teaching or practice area in SC. (Mark only one)
Home Health
Neonatology
Dialysis
17
10
21
Other Generalized Community Health
Pediatrics
Other Specialty Medical/Surgery Care
01
06
05
(e.g. Family Planning, School Health)
Emergency Care
Critical Care
Psychiatric/Mental Health
09
11
07
(
e.g. ICU, PCU, CCU)
General Nursing Practice
Oncology
Mental Retardation/Developmental Disability
02
18
15
Geriatric Nursing
Anesthesiology
Nursing Administration
03
13
16
04
Obstetrics/Gynecology
OR/Recovery Care
Outcomes Review
14
19
(e.g. QA, PRO, Utilization Management)
Occupational Health
Rehabilitation
Other, Specify _______________________
22
20
08
5. RN/APRN ONLY Indicate the type of position that you presently hold in SC. (Mark only one)
Nursing Administrator/
Head Nurse or Assistant
Clinical Nurse Specialist
01
05
08
(Master’s Level Medical Acts)
Director or Assistant
C
ertification ___________________________________
Nursing Consultant
Staff/general Duty/Office
11
Clinical Nurse Specialist
02
06
(Master’s Level No Medical
Acts) Certification _________________________
Supervisor or Assistant
CNM (APRN)
Other, Specify _____________________________
03
07
16
Nursing Instructor
CRNA (APRN)
NP (APRN)
04
10
13
(Includes In-Service)
Clinical Nurse Specialist (No Masters Degree-No Medical Acts)
12
Signature_____________________________________________________________ Date__________________________________
* The disclosure of the social security number for identification purposes is authorized and mandated by state and federal statutes. The social
security number is not subject to disclosure as public information.
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