1 LIC-102 03/01/18

Oregon Application for LPN/RN by Endorsement

NOTE: This application is available online for US nursing program graduates that have passed the SBTPE/NCLEX examination, and were licensed in another state/US jurisdiction. Apply online by going to the OSBN website at www.oregon.gov/OSBN.

Section 1: Application Information • ATTENTION: Per ORS 678.050(3)(b), all LPN/RN application fees must be paid for by the applicant. Third party

payments will be returned to the payee, fees will remain outstanding, and processing will be delayed. • Name Change: If the name on your official transcripts is different from the name you listed on your application, include

form OSBN-613 Name Change and/or Address Request Form and proof of legal name change documentation with your application.

• OSBN Mailing Address: Submit the original application – copies are not accepted. Mail application documents andcheck or money order to OSBN at: 17938 SW Upper Boones Ferry Rd, Portland OR 97224.

• Background Check: OSBN requires a national fingerprint-based criminal background check in order to apply forand be issued a nursing license in Oregon. Criminal background checks completed by employers, other agencies, orother state/US jurisdictions are not accepted for this requirement. Electronic fingerprinting services are provided byFieldprint Inc., an independent contractor with the State of Oregon.

• Schedule Appointment: Once OSBN has received your application and full payment, you will be sent an email to theaddress you provided on the application with instructions on how to register with Fieldprint Inc to schedule and pay foryour fingerprinting appointment.

• Fingerprinting Fee: In order to schedule a fingerprinting appointment, Fieldprint Inc charges a separate $64.50 servicefee. This fee is collected during Fieldprint’s online registration process.

• Application Status: You may track the progress of your application using the Application Status Wizard available on theOSBN website at: www.oregon.gov/OSBN. The status of a required item is updated online as processed by staff.

Section 2: Application Fees- ALL OSBN FEES ARE NON-REFUNDABLE.

Section 3: Nursing Education- Provide proof of completion from your qualifying nursing program. US Graduates (includes graduates of Puerto Rican RN nursing schools between 1991-2006 who took the RN NCLEX): Request from your school official sealed transcripts sent directly to OSBN, or if the school subscribes to an electronic document transfer network, request the service to the OSBN email address osbn.transcripts@state.or.us.

Non-US Graduates: Canadian nursing graduates after January 1, 2015 who took the NCLEX in Canada must submit sealed official transcripts sent directly to OSBN from their nursing school. All other international nursing school graduates must have a credentials evaluation done by a qualified evaluation service. Request the service to send an official copy of your evaluation directly to OSBN to meet requirements.

Section 4: Nursing Practice- You must meet the requirement in one of the following ways: 1. Completion of your initial nursing program within 5 years from date of application (practice is waived); OR2. You have at least 960 hours of LPN/RN nursing practice in the 5 years from date of application; OR3. Graduation from a nurse re-entry program in the last 2 years from date of application. Review and approval of the program

by Board staff is required before a license is issued.

Section 5: License Verification Request verification of both your original and most recent state nursing licensure from NURSYS, the national licensing and regulatory database at www.nursys.com. NOTE: OSBN does not accept NURSYS QuickConfirm printouts. You must register with NURSYS and request verification be sent to Oregon. If the state does not participate in NURSYS, request verification from the state nursing regulatory agency to be sent directly to OSBN.

Application Type Fee Description

LPN/RN by Endorsement $204 Surcharge: Application fees include a $9 surcharge remitted to the Oregon Center for Nursing (OCN) to fund the Oregon Nursing Advancement Fund created by Oregon Senate Bill 72 in 2015.

2 LIC-102 03/01/18

Oregon Application for LPN/RN by Endorsement

IMPORTANT: Faxed/emailed applications are not accepted. You may fill out the form electronically then print it out to sign and mail to OSBN. All LPN/RN application fees must be paid for by the applicant. Third party payments submitted with an application will be returned to the payee, fees will remain outstanding, and processing will be delayed.

Section 1: Application Type

Last Name:

First Name:

Middle Name:

Former Name(s):

Street Address:

Country:

US Residents: (select from each box)

City: State: Zip:

International Residents: (list your city, state/province, and postal code here) Primary Phone:

Secondary Phone:

Email:(required)

NOTE: OSBN uses the email address on file for all application and licensing renewal notifications. It is your responsibility to keep information on file current with OSBN to ensure receipt.

Section 3: Personal Identifiers Gender: Female Male Date of

Birth:

Social Security Number (required):

Section 4: Nursing Education List your initial nursing education you completed that qualified you to sit for the SBTPE/NCLEX examination. Name of School:

City:

If US School: Select State/Jurisdiction

Country:

Degree/Certificate Awarded:

Graduation Date: (mm/dd/yy)

Full Name on Transcript:

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ATTENTION: Your SSN is required per ORS 25.785 and will be disclosed to entities and used for the purposes listed in OAR 851-001-0030 (2). Refusal to provide your SSN will result in denial of licensure/certification. This denial will be reported to the National Practitioner Databank, as authorized by 42USC Section 666(a) (13). If you are currently working on a US Visa (H1B, I-766 or other current federal government form authorizing you to work in the US), please submit copies of your passport and the Visa along with this application. If you are attending school on an F1 Visa, please provide a copy of the I-94 and I-20 signed by the designated school authority.

I completed a nursing program outside the US. I passed the NCLEX in another state and was issued a license. RN

LPN

Section 2: Name and Address Information

I completed a Puerto Rican RN nursing program between 1991 and 2006 and passed the RN NCLEX in Puerto Rico and was issued a license.I completed a Canadian nursing program after January 1, 2015 and took the NCLEX in Canada.

3 LIC-102 03/01/18

NOTE: This page is for your information only. Please remove from your completed application before submitting to OSBN.

Section 5a: Instructions for Disclosure SectionThe following instructions provide you with specific information for what is required to continue processing your application. You are responsible for contacting the appropriate agencies to obtain the required documents to submit with your application. Please read the following instructions carefully. Your application will not be considered complete until all documents are received.

Question 1(a) & (b) & (c): Use of Alcohol or Drugs If you answered YES to one or more of these questions, provide a detailed written explanation. Describe your alcohol/drug use history and details of any treatment with relevant dates. Provide any available documentation of your sobriety (e.g. letters, program records, or certificates of completion), if applicable.

You may answer NO if: You are currently enrolled in Oregon’s Health Professionals Services Program (HPSP) as a Self-Referral. “Self-referral” means that you have independently and voluntarily enrolled in HPSP, and are being monitored. If you have had a Board investigation that resulted in your enrollment, you must answer YES.

Question 2: Ability to Practice Nursing Safely If you answered YES, provide a detailed written explanation of your condition, its effects, and how you manage your condition.

Question 3: Criminal History If you answered YES, provide a detailed written explanation. Describe the incidents that led to each arrest/charge, and the surrounding circumstances. Include relevant dates, the city and state where the incidents occurred, and the outcome of any criminal charges. Provide a copy of the court judgment and sentencing order or court order of dismissal, and documents providing evidence that you have completed or are in compliance with any court-ordered activities.

Question 4: Investigations for Abuse or Mistreatment If you answered YES, provide a detailed written explanation. Provide the name of the agency that conducted the investigation. Provide documentation of the outcome of the investigation and any investigative reports.

Question 5(a) & (b): Investigations for Healthcare Violations a) If you answered YES, provide a detailed written explanation. Describe the alleged violation with relevant dates.

Provide the name of the agency that conducted the investigation. Provide documentation of the outcome of the investigation and any investigative reports.

b) If you answered YES, provide a detailed written explanation. Indicate the law or rule that was found to be violatedwith relevant dates. Provide documentation of the final determination.

Question 6(a) & (b): Discipline for Healthcare Violations If you answered YES, provide a detailed written explanation. Describe the incidents that led to the discipline and the surrounding circumstances with relevant dates. Provide documentation of the final determination.

Question 7: Credentialing Privileges If you answered YES, provide a detailed written explanation. Describe the incidents that led to the action against your privileges, and the surrounding circumstances with relevant dates. Provide documentation of the final determination.

Question 8: Malpractice If you answered YES, provide a detailed written explanation. Describe the incidents that led to the action for notice or civil judgement against you. Provide documentation of the final determination.

4 LIC-102 03/01/18

Section 5b: Disclosure Before answering the questions below, please review the instructions for information to provide regarding any disclosure(s). Providing false, misleading, or incomplete information is considered falsifying an application and is grounds for denial of your application or discipline on your license/certification.

I understand I must provide the Oregon State Board of Nursing (OSBN) with any updates to information required in this application while it is pending.

1

a) In the last two years, have you used alcohol or any drugs in a way that could impair yourability to practice nursing or perform nursing assistant duties with reasonable skill andsafety?

b) In the last two years, have you been diagnosed with or treated for an alcohol or any drug-related conditions?

c) In the last two years, have you used any illegal drugs, or prescription drugs in a mannerother than prescribed?

ATTENTION: You must answer YES if you are enrolled in an impaired nurse program in any state or jurisdiction including Oregon. If you are a self-referral to the Oregon Health Professionals Services Program (HPSP), please review the disclosure instructions for Question 1 that include the definition of “self-referral”, before answering any of these questions.

YESExplain

YESExplain

YESExplain

NO

NO

NO

2 Other than any information you may have provided in Question 1, do you have a physical, mental or emotional condition that could impair your ability to practice nursing or perform nursing assistant duties with reasonable skill and safety?

YESExplain

NO

3

Other than a traffic ticket, have you ever been arrested, cited, or charged with an offense?

ATTENTION: This includes outstanding restraining orders, all arrests, citations, or charges for felony or misdemeanor crimes, even if you were not convicted of any charge (for example- no charges were filed, case was dismissed, or you entered a diversion program). Driving under the influence must be reported here.

YESExplain

NO

4 Have you ever been part of an investigation for any type of abuse or mistreatment, in any state or jurisdiction? Include any pending investigations.

ATTENTION: You must answer YES to this question even if the allegation was not substantiated.

YESExplain

NO

5

a) Have you ever been investigated for any alleged violation of any state or federal law, rule,or practice standard regulating a health care profession? Include any pendinginvestigations.

b) Have you ever been found in violation of any state or federal law, rule, or practice standardregulating a health care profession?

ATTENTION: Question 5a) and 5b) include disclosure of any civil, criminal, administrative, licensing, or credentialing proceedings.

YESExplain

YESExplain

NO

NO

6

a) Has an agency ever taken action against any healthcare license or certificate you haveheld in any other state or jurisdiction?

ATTENTION: Question 6a) includes the disclosure of a denial, revocation, suspension, restriction, reprimand, censure, probation, loss of privileges, or any other formal or informal action.

b) Have you ever withdrawn an application, or surrendered a license or certificate to avoidany of the actions listed above?

YESExplain

YESExplain

NO

NO

7 Have you ever had privileges to practice in a credentialed facility or participation in a federally qualified insurance program (e.g. Medicare or Medicaid) denied, restricted, suspended, revoked, or terminated for cause?

YESExplain

NO

8 Have you ever had a notice filed or a civil judgement awarded against you for malpractice, negligence, or incompetence relating to your ability to practice as a health care professional?

YESExplain

NO

Applicant Last Name First Name:

5 LIC-102 03/01/18

Section 6: Nursing License Information List below the state you were initially licensed in to practice after passing the SBTPE/NCLEX exam, AND your current, or most recent state of licensure. If you are practicing in a compact state, list the state license you are using to practice.

Original State: Current State:

Section 7: Work HistoryLast day of nursing practice:(mm/dd/yy)

Start with your most recent practice. If you have not practiced in the last 5 years, list the last position prior to leaving practice.

Company Name:

Phone: Country:

Site Address:

City: US Zip Code:

Position Title:

License Number:

Licensing State:

Still Employed: Yes No Paid Practice: Yes No

Start Date (mm/dd/yy):

End Date (mm/dd/yy):

Total number of practice hours in position (required): Company Name:

Phone: Country:

Site Address:

City: US Zip Code:

Position Title:

License Number:

Licensing State:

Still Employed: Yes No Paid Practice: Yes No

Start Date (mm/dd/yy):

End Date (mm/dd/yy):

Total number of practice hours in position (required):

Section 8: Authorization I understand I have a duty to provide the Oregon State Board of Nursing with any updates to information required in this application while it is pending. I hereby certify that I have read this application, and that the information provided is true and correct. I have personally completed this application. I am aware that falsifying an application, supplying misleading information or withholding information is grounds for denial or discipline of license/certification. I am aware that the Oregon State Board of Nursing will conduct criminal records checks through the Oregon Law Enforcement Data System (LEDS) and the Federal Bureau of Investigation (FBI).

I do not want my name and address shared with non-state agencies or for non-public health planning purposes. I understand thisdoes not apply to requests made to OSBN for public information as authorized by ORS 192.420.

Printed First and Last Name

Applicant Signature:

Date: (mm/dd/yy)

Notice to Applicants with Disabilities: If you have a disability and require special materials or assistance to complete this application, please contact OSBN at 971-673-0685. If you are hearing impaired, you may contact OSBN through the Oregon Relay Service at 1-800-735-2900

LIC-616 08/01/17

Oregon State Board of Nursing Approved Independent Services for

Credential Evaluations & Language Proficiency Exams The following is a list of Oregon State Board of Nursing (OSBN) approved credential evaluation agencies and language proficiency examination entities who independently provide education equivalency and language proficiency evaluations for nurses who have completed their nursing education outside of the United States. Contact the individual agency directly for additional information. Approved Credential Equivalency Evaluation Agencies 1. Commission on the Graduates of Foreign Nursing Schools (CGFNS)

3600 Market St Ste 400 Philadelphia PA 19104 Phone: 215-222-8454 Website: http://www.cgfns.org/ • OSBN accepts the following CGFNS-prepared documents for credential evaluations: 1) Credentials Evaluation

Service (CES) Full Healthcare Profession & Science reports; 2) A valid CGFNS certificate, or 3) A valid VisaScreen certificate for meeting education equivalency requirements.

• Evaluations completed prior to applying for Oregon nursing licensure may be accepted by OSBN if they are still considered valid by CGFNS.

• All credential evaluations must be received directly from CGFNS to ensure primary source verification- a copy of an evaluation received directly from the applicant will not be accepted.

• A valid CGFNS certificate or VisaScreen certificate meets OSBN requirements for a credential evaluation, as well as proof of English language proficiency.

2. Educational Records Evaluation Service (ERES)

601 University Ave Ste 127 Sacramento CA 95825 Phone: 916-921-0790 or 866-411-3737 Website: www.eres.com

• Evaluations of equivalent qualifying nurse education completed prior to applying for Oregon nursing licensure may be accepted by OSBN if they are still considered valid by ERES.

• All credential evaluations must be received directly from ERES to ensure primary source verification- a copy of an evaluation received directly from the applicant will not be accepted.

3. International Education Research Foundation (IERF)

PO Box 3665 Culver City CA 90231 Phone: 310-258-9451 Website: http://ierf.org • Evaluations of equivalent qualifying nurse education completed prior to applying for Oregon nursing licensure may

be accepted by OSBN if they are still considered valid by IERF.

• All credential evaluations must be received directly from IERF to ensure primary source verification- a copy of an evaluation received directly from the applicant will not be accepted.

4. Educational Perspectives PO Box A3462 Chicago IL 60690 Phone: 312-421-9300 Website: https://www.edperspective.org/ • OSBN accepts the following type of Educational Perspectives-prepared credential evaluation: Course-by-Course

Evaluation for meeting education equivalency requirements.

LIC-616 08/01/17

• Evaluations of equivalent qualifying nurse education completed prior to applying for Oregon nursing licensure may be accepted by OSBN if they are still considered valid by Educational Perspectives.

• All credential evaluations must be received directly from Educational Perspectives to ensure primary source verification- a copy of an evaluation received directly from the applicant will not be accepted.

5. Josef Silny & Associates, Inc., International Education Consultants

7101 SW 102nd Ave Miami FL 33173 Phone: 305-273-1616 Website: www.jsilny.org • Evaluations of equivalent qualifying nurse education completed prior to applying for Oregon nursing licensure may

be accepted by OSBN if they are still considered valid by the organization that prepared the evaluation.

• All credential evaluations must be received directly from Josef Silny & Associates, Inc., International Education Consultants to ensure primary source verification- a copy of an evaluation received directly from the applicant will not be accepted.

OSBN-Approved Language Proficiency Examinations A language proficiency examination may be required by OSBN when applying for LPN/RN Licensure by Examination if they completed an education program outside of the United States where textbooks and academic instruction were predominantly in a language other than English. The following three examinations are approved by OSBN to meet the requirement for licensure, upon receipt of proof of successful test results from the evaluation service. OSBN will accept passing examination results from any of the three entities listed below for an examination taken within two years from the date of application for licensure. For more information regarding English language proficiency requirements, see the Oregon Nurse Practice Act; Division 31 Standards for Licensure of Registered Nurses and Licensed Practical Nurses; Oregon Administrative Rule (OAR) 851-031-0006(f). 1. International English Language Testing System (IELTS)

100 E Corson St Ste 200 Pasadena CA 91103 Phone: 626-564-2954 Website: http://www.ielts.org • Academic Module examination type accepted. General Training version does not meet requirement.

2. Education Testing Service (ETS) Test of English as a Foreign Language (TOEFL)

PO Box 6151 Princeton NJ 08541 Phone: 1-800-468-6335 Website: http://www.ets.org/toefl/ • Widely accepted English language tests for admissions and in-class use • Internet-based Test (iBT) and paper-based (PBT) examination testing formats

3. Education Testing Service (ETS) Test of English for International Communication (TOEIC)

Rosedale Rd Princeton NJ 08541 Phone: 1-609-771-7170 Website: http://www.ets.org/toeic/ • Global standard for assessing workforce English proficiency • Designed specifically to measure the everyday English skills of people working in an international environment. • Paper-based examination testing format