II~::*r-Jbi6R~NM~i~~ cHANG~s · iiitatq pfl cai.ifiotlnia busi~iebs. cohsumer tllirviccr;_ and...

IIITATQ Pfl CAI.IfiOtlNIA BUSI~IEBS. COHSUMER tlliRVICCR;_ AND IIOI!f)ING AGfNCI' • (.'IOVF.RNOR EDMUN013. BROWN JR

BOARD OF REGISTERED NURSING

DEPARTMENT Of' CONSYMilfl AFfl\lRB PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

GENERAL INSTRUCTIONS AND APPLICATION REQUIREMENTS FOR NURSE PRACTITIONER (NP) CERTIFICATION

GENERAL INSTRUCTIONS

Nurse Practitioner certification eligibility requires the possession alan active California registered nurse (RN) license (California Code of Regulations, Section 1482).

If you do ~~!:RR~!l.~ss an actiX&lf~li(9,'Qia RN.J,J2~1\~7 and have ·Q.~YW i'l~gtied for a C~!if?rnia RN tic~,~fe, an Application for Caltfor~!li\1:i~f1l:<~!~~psure b,~i~~pr\le)J)ent ~\il;\ll~~I!!O J:>e subrn~~~~;: lfyow have had::~ p~rmanent Q~Yfornta RN license, you must ~~lherreh:t'lWor rea¢(ii/a!e the Catiformt~ RN ticen:;e. ::: /' · .... ·:. <';

:;;;:;::: . ·?(\ @\ ~;;;~;} ·:::\\ f~U (>::' \)~. ~~t~i~: Nurse Prap:!,Woner a~ptication::1\'ie is an _earnedi[f%~; there!ef~, wh~Qan applicant is foghd in~tj~ible the ~~plication fee is n?t refunded. ~Ul'roces$t~g ttmell'::for certtftcatton;:: (nay vat:£:,:;:;deper:@ng . on the receiPt of •,q.Qcument<!m~ from academtc programs,'f!:i.i-J>R9i;:t\l~iis/naticiitat qtg§(!i?ation~; ''" evaJ~~(ors. !"roptjs$li;\g a Nur~e: Practi!fiJner ce®'ffcation application indicating 'fi''il~R'i'&\ion(s) an~/pr disciplinary ~cli9(1(~\i\flily takl/:tongef''A pend.fDd appli~~fion fite~~·not a disctosabte public rec~fo9; the~~:f:(Jre, an il\!ilPiicant must sj~Jl'a'•retease of lNprmation befor~•i\R.~t, .• !:i9~SdQf Re~Jjl1ered Nursing will release infg[;tnation f~lating t~.t'W application !;~(he public, inclu~J,j1ig employers, ~el~!llri#§:'qfptf)er thir~parties. Once you are cerlllleM1 your add.J7ss of ~?ord must be dts9tosed to the pu~~\.~ upon request : !:\

.- --·-··- ~r> \.:·< -~~~l:> .. )t;: · {.:·_ .-.;.-.·. NAI\II~::*r-Jbi6R~NM~i~~ cHANG~s ··· n -~~ ······· ·' ·· II.

California Code of Regulations, Section 1409.1 requires that you notify the Board of Registered Nursing of all name and address changes within thirty (30) days of any change. You may call the Board of Registered Nursing regarding the change of address of record. If you have changed your name, please submit a tetter of explanation along with legal documentation of the name change to the Board. Examples of acceptable forms of legal documentation are birth certificate, marriage certificate, divorce decree and/or court documents, social security card or passport. A copy of a driver's license is not acceptable.

jl[. StDCIAL S~'CURIT:'('NUMB.~i& INDIV)(e>'WAL TAXR~YER IDENTIFICATION NUMBER (ITIN)

Disclosure of your social security number/lTlN is mandatory, Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA 405 (c)(2)(C)) authorize collection of your social security number/ITIN, Your social security number/ITIN wHI be used exclusively for tax enforcement purposes, for purposes of compliance w"tth any judgment or order for family support in accordance with Section 11350.6 of the Welfare and Institutions Code, or for verification of licensure, certification or examination status by a licensing or examination entity which utilizes a national examination where licensure is reciprocal with the requesting state. lf you fail to list your social security number/lTlN. your application for initial or renewal license/certification will not be processed. You witt also be reported to the Franchise Tax Board, which may assess a $100 penalty against you. Questions regarding the Franchise Tax Board should be directed to (BOO) 852-5711.

ALERT: Effective July 1, 2012, the Board of Registered Nursing is required to deny an application for licensure and to suspend the license/certificate/registration of any applicant or licensee who has outstanding tax obligations due to the Franchise Tax Board (FTB) or the State Board of Equalization (BOE) and appears on either the FTB or BOE's certified lists of top 500 tax delinquencies over $100,000, (AB 1424, Perea, Chapter 455, Statutes of 2011).

(Rev 05114)

GENERAL INSTRUCTIONS -(continued)

.IV> •. RI;:PORTING·PRIQR·CONVICTIQI\IS OR·OISCIPLINI!l•AGAIN.ST LiCEN$E:$/CER.J;fi=ICAT.Ii.$.

Applicants are required under law to report all misdemeanor and felony convictions. "Driving under the influence" convictions must be reported. Convictions must be reported even if they have been adjudicated, dismissed or expunged or even if a court ordered diversion program has been completed under the Penal Code or under Article 5 of the Vehicle Code. Also, all disciplinary action against an applicant's nurse practitioner, registered nurse, practical nurse, vocational nurse or other health care related license or certificate must be reported. Also any fine, infraction, or traffic violation over $1,000.00 must be reported.

Failure to report prior convictions or disciplinarv action is considered falsification of application and is grounds for denial of licensure/certification or revocation of license/certificate.

When reporting prior convictions or disciplinary action, applicants are required to provide a full written explanation of: circumstances surrounding the arrest(s), conviction(s), and/or disciplinary action(s); the date of incident(s), conviction(s) or disciplinary action(s); specific violation(s) (cite section of law if convicted), court location or jurisdiction, sanctions or penalties imposed and completion dates. Provide certified copies of arrest and court documents and for disciplinary proceedings against any license as a RN or any health-care related license; include copies of state board determinations/decisions, citations and letters of reprimand.

NOTE: sobriety date.

Examples

•

• on official .··~,~···! •te'tl1f.i~ill':frol n~~~:~.~~~~~~~ professionals, professional counselors, parole or probation officers, Group 't':''

, health

other individuals in positions of authority who are knowledgeable about your rehabilitation efforts.

• Letters from recognized recovery programs and/or counselors attesting to current sobriety and length of time of sobriety, if there is a history of alcohol or drug abuse.

• Submit copies of recent work evaluations.

• Proof of community work, schooling, self-improvement efforts.

• Court-issued certificate of rehabilitation or evidence of expungement, proof of compliance with criminal probation or parole, and orders of the court.

All of the above items should be mailed directly to the Board by the individual(s) or agency who is providing information about the applicant. Have these items sent to the Board of Registered Nursing, Licensing Unit - Advanced Practice Certification (NP), P.O. Box 944210, Sacramento, CA 94244-2100.

It is the responsibility of the applicant to provide sufficient rehabilitation evidence on a timely basis so that a certification determination can be made.

An applicant is also required to immediately report, in writing, to the Board any conviction(s) or disciplinary action(s) which occur between the date the application was filed and the date that a California Nurse Practitioner certificate is issued. Failure to report this information is grounds for denial of licensure or revocation of license/certificate.

NOTE: The application must be completed and signed by the applicant under the penalty of perjury.

(Rav 0&14) 2

GENERAL INSTRUCTIONS- (continued)

V. TEMPORARY NURSE PRACTl'r:IONER C~R:nFICATI;

The Nurse Practitioner certification applicant may apply for the Temporary Nurse Practitioner Certificate (TC/NP) only if the applicant does not possess a permanent California RN license at the time of application.

Eligibility for the TC/NP is based on:

VI.

• Possession of a temporary California RN license (TL).

• A completed Application for Licensure by Endorsement which includes written verification from a state where you hold an active and permanent RN license and results from the background check received from the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). You also must request an official transcript be sent directly from your nursing program .

•

Street Address for overnight or in-person delivery:

Web Site:

Advanced Practice Unit- NP Certification Board of Registered Nursing 1747 N. Market Blvd., Suite 150 Sacramento, CA 95834-1924

www.rn.ca.gov

Vd'l,' CALIFORNJA NURSING PRA¢ifiCE ACT

California statutes and regulations pertaining to Registered Nurses/Nurse Practitioners may be obtained by accessing the Board of Registered Nursing web site at www.rn.ca.gov

(Rev OS/14) 3

APPLICATION REQUIREMENTS FOR NURSE PRACTITIONER (NP) CERTIFICATION

M~JiJ:U;)"D C>NE (California Graduates Only)

Successful completion of a nurse practitioner program of study which conforms with the Board's educational standards set forth in the California Code of Regulations Section 1484.

Documentation submitted directly to the Board of Registered Nursing:

1. Completed Application for Nurse Practitioner (NP) Certification and applicable fee.

2. Completed Verification of Nurse Practitioner Academic Program form submitted by the nurse practitioner academic program. (Page 8)

3. Official transcripts for the completed nurse practitioner academic program submitted by the nurse practitioner academic program.

Certification :9~· a,.national om,an:i!!.a.tioq/asso<;:.~\ign,,)!lllJose stano<m:t~.:::\!.f:<il:;equivalent:~9::those set f~rth in the California

:::::e].~~:~~~~l~~:~:n~~~::~;y'·~o· the B~~C:;·~~hlsterJ~e::i·::: , •• ,:~~tiji... J,~, 1. < Cofr1pleted .(~plication for ~l~se Pragtltioner,i,NP) Certification ~Jd a~~)jcable fe~ .. 2. .t Completed ~~~iff~~{!~n of r~·tr~e );!;~~titlo~~f't~~~~.~mic Pr~ram 'fCJrm sub~\fied by the nurse

·. pfaytitioner il)illldemic prograr)'i:.',;,@~~):j8) \:: i'< .: ;:; ... c6IJ]pieted ~~rification of N~t~e P~actitioner ~~rtification by,,~~Honai<)i'n~nizati'$h/Association fort;),J.$ubmit(~d by the respec\1&'$ organization. Gfage 9) .:•? ·•:: .. •:•• : (Selii;page ~fr;r a fist of Natio:ri'~1 Organizationslf.\s:sociations) ?'i •·••• ·'· · Offici~( tran~~r[pt~i f~~:;'~he J~~pleted nurse ~~~~\lif9'~~1;. ac~kmic progra~ sub~llt~d ~Y the nurse practitioner academic program.

3.

4.

A registered nurse who has not completed a nurse practitioner program of study which meets the Board of Registered Nursing's educational standards as specified in the California Code of Regulations Section 1484.

Documentation submitted directly to the Board of Registered Nursing:

(Row 05114)

1. Completed Application for Nurse Practitioner (NP) Certification and applicable fee.

2.

3.

4.

5.

6.

7.

Completed Verification of Nurse Practitioner Academic Program form submitted by the nurse practitioner academic program. (Page 8)

Completed Verification of "Clinical Competency" as a Nurse Practitioner form submitted by a nurse practitioner. (Page 1 0)

Completed Verification of "Clinical Competency" as a Nurse Practitioner form submitted by a physician. (Page 11)

Completed Verification of "Clinical Experience" as a Nurse Practitioner form submitted by the physician and/or nurse practitioner. (Page 12)

Official transcripts for the completed nurse practitioner academic program and/or academic program submitted by the applicable program.

Curriculum and course descriptions for the completed academic program for the period of time attended.

4

APPLICATION REQUIREMENTS FOR NURSE PRACTITIONER (NP) CERTIFICATION- (continued)

The national organizations/associations listed below have met the certification requirements that are equivalent to the Board's standards for nurse practitioner certification:

• American Academy of Nurse Practitioners (AANP) P. 0. Box 12846, Austin, TX 78711

•

•

•

•

(Ro~ 05114)

(512) 442-4262 www.aanp.org

American Nurses Association -American Nurses Credentialing Center (ANCC) 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910-3402 (800) 284-2378 www.nursecredentialing.org

Pediatric Nursing Certification Board 800 S. Frederick Ave., Suite 204, Gaithersburg, MD 20877-4152

&§!~§.1':94Jc2767 {::::;,:,:: :: : : ;;~ :·· ; ::;,. ..:'.> / •.• •.··.: . .i.(.•:.::.i.i.:' .. i' .;:t, · .• • .• :·) .. ··.,·.•.·.· •• ,,: .• : ~bhblforg '••<·.••• · · { :" •·• ''''"·'·•'::•:l':\ ., · .. .:' \:,:::::. :~:it ·-;}:;~~- ;::::::~: ~:::;:-· ·.:::~:·_'::_ :t::;~ --~:.:-, ·;:;.~·i!; ;.~<_,;.;

N~~nal ce'~jf:icatio~porporation fo~\~~e Obst~~ric, oM~cologic and Ne<1%~taf{~~rsing s~9ialties (NCC)

t~2~~~11lf~7str~~t; sUite 11oo, 1~rgo, IL.6.0611 :·: '>'··•· / ;.; t ~:qgywebsite.org :/ ,/ <. :

Arj\~rican Associati~~ of Criticai-Cad~·~u~ses (AACN) . J(''•.· · <\) \ 101 Colurn!Jia, Alis~l'Viejo, CA 9265.~A 109 :: ·· :, (890) 899;2226 ···::·. •·' .•. ,.,,... ) :. '

~Ww.aacn:4~9 : :.·::,··· \ •t .c: ', <: -; ~:i:~: ~~\(:~;;::>::_·::·_:_:-·-·: ' '<:_::

PLEASE REFER QUESTIONS REGARDING THE NURSE PRACTITIONER APPLICATION PROCESS TO THE ADVANCED PRACTICE UNIT IN SACRAMENTO AT (916) 322-3350.

5

VIII. HONORABLY DISCHARGED MEMBERS OF THE U.S. ARMED FORCES RECEIVE EXPEDITED REVIEW

(Rev. 07/16)

Notwithstanding any other law, on and after July 1, 2016, a board within the department shall expedite, and may assist, the initial licensure process for an applicant who supplies satisfactory evidence to the board that the applicant has served as an active duty member of the Armed Forces of the United States and was honorably discharged (Business and Professions Code section 115.4.).

If you would like to be considered for this expedited review and process, please provide the following documentation with your application:

1. Report of Separation form.

The report of separation form issued in most recent years is the DD Form 214, Certificate of Release or Discharge from Active Duty. Before January 1, 1950, several similar forms were used by the military services, including the WD AGO 53, WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD and the NAVCG 553.

Information shown on the Report of Separation may include the service member's date and place of entry into active duty, date and place of release from active duty, last duty assignment and rank, military job specialty, military education, total creditable service, separation information, etc.

6

PTATn QP CAI.IPOI~NIA 1!\l\iiNI-SS GONSUMI:J~ S(,JWIGFS_ AND HOU~;itKl AGENCY • GOVEI~N()I~ ~:DMUNO (;, BHOWN .Ji~.

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

Clca O&PAilfMSNT OF CONS:UMEil A'fiPAIAS

APPLICATION FOR NURSE PRACTITIONER (NP) CERTIFICATION I APPLICATION FEE - $150.00

Number and Street

- MILITARY HONORABLE DISCHARGE~ Check here If you served as an active duty _ member of the Armed Forces of the United States and were honorably discharged,

RN EDUCATION

TYPE OF PROGRAM:

D ASSOCIATE DEGREE

Name of Professional Registered Nursing Program D DIPLOMA D BACCALAUREATE DEGREE D MASTERS DEGREE/NURSING

City State Country Entrance Date:

Graduation/Completion Date:

N[IJRSI; ~ .t~tr~'rl\ONEIUO.UCATION

TYPE OF NURSE PRACTITIONER ACADEMIC PROGRAM:

Name of Nurse Practitioner Academic Program D CERTIFICATE D MASTERS D POST-MASTERS

City State Country

Entrance Date: Area of Specialization:

Graduation/Completion Date:

(Rev 07/11!)

7 (Questions on both sides of page)

NAME OF APPLICANT:

NURSE PRA<:TXTIONER PROFESSJ;OI'\IA!;CERTIFICATION f1fAuoHr::abli11t

Name of Organization/Association

Area of Specialization:

METHOD OF CERTIFICATION:

0 EXAMINATION

0 OTHER (Please Explain):

Original Date of Certification:

Certification Number: Current Recertification Cycle Dates:--------

Have you applied for a Nurse Practitioner certificate in California? If yes, name on previous application:

Date Submitted:-----

0 YES

0 NO

Have you ever been issued a Nurse Practitioner certificate in California? 0 0 NO

0 NO

0 NO

I understand that I am required to report immediately to the California Board of Registered Nursing if I am convicted of ANY offense that occurs between the date of this application and the date that a California registered nurse license is issued. I am also required to report to the California Board of Registered Nursing any disciplinary action and/or voluntary surrender against ANY health-care related license/certificate that occurs between the date of this application and the date that a California registered nurse license is issued. I understand that failure to do so may result In denial of this application or subsequent disciplinary action against my license/certificate.

I certify, under penalty of perjury under the laws of the State of California, that all information provided in connection with this application for licensure is true, correct and complete. Providing false information or omitting required information is grounds for denial of licensure or license revocation In California.

SIGNATURE OF APPLICANT DATE

"SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT

Attach a recent 2"x2" passport type photograph.

Please tape on all four sides.

Head and shoulders only

Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code and Public Law 94·455 (42 USCA (c)(2)(C) authorizes collection of your social security number, Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support In accordance with section 17520 of the Family Code, or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fall to disclose your social security number, your application for Initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.

(Re'l 0111$)

8

VERIFICATION OF NURSE PRACTITIONER ACADEMIC PROGRAM

TO BE COMPLETED BY APPLICANT: Please complete Section A and forward to the program director/representative for the nurse practitioner academic program for completion. Official transcripts submitted must Include all completed coursework with the certificate/degree status conferred and must be sent directly to the Board of Registered Nursing by the Registrar's Office/Transcript Office. A processing fee may be required for the submission of the official transcripts.

FIRST NAME:

ADDRESS:

MIDDLE NAME:

SOCIAL SECURITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:

The above applicant has applied for a nurse practitioner certification in CaliFornia. Please provide the following Information and mall to the Board of Registered Nursing at the above address.

NAME OF NURSE PRACTITIONER ACADEMIC PROGRAM: TELEPHONE NUMBER: ( )

ADDRESS: Number & Street City State Postal/Zip Code

TYPE OF PROGRAM: Entrance Date:

0 CERTIFICATE (Mont/J!Oay/Year)

0 MASTERS Completion Date: 0 POST-MASTERS (Month/Day/Year)

SPECIALTY: Date Certificate/Degree Status Conferred: Monlh!Da '/Year.

OUT OF STATE NP ACADEMIC PROGRAM GRADUATES: Recognized by Commission on Collegiate Nursing Education: 0 0

YES NO If yes, Name: Program Approval Cycle Dates:

I certify under penalty of perjury that the documentation regarding the completion of the nurse practitioner academic program for the above named applicant is true and correct.

SIGNATURE: TITLE: (DATE)

9

VERIFICATION OF NURSE PRACTITIONER CERTIFICATION BY NATIONAL ORGANIZATION/ASSOCIATION

METHOD2 TO BE COMPLETED BY APPLICANT: Please complete Section A and submit to the applicable national organization/association to verify your nursing practitioner certification status. A fee is required by the national organization/association for the processing of the verification form.

DATE OF BIRTH: (Month/Day/Year)

lB. TO BE COMPLETE[)) B'Y THE cE'pjTtFti!li.Q)l!A'ttO:N~I.i QII~AIIILZATIQN I ASSOC:tATI.ONI The above applicant has applied for a nurse practitioner certification In California. Please provide the following Information and mall to the Board of Registered Nursing at the above address.

NAME OF CERTIFYING NATIONAL ORGANIZATION/ASSOCIATION TELEPHONE NUMBER: ( )

ADDRESS: Number &. Street City State Postal/Zip Code

METHOD OF CERTIFICATION: CERTIFICATE NUMBER: ORIGINAL DATE OF CERTIFICATION:

NURSE PRACTITIONER SPECIALTY AREA:

CURRENT RENEWAL CYCLE DATES FOR CERTIFICATION/RECERTIFICATION: (If not applicable, please explain)

From: To: Month Yllar Month Year

I certify under penalty of perjury that the documentation regarding the nurse practitioner certification status for the above named applicant is true and correct.

SIGNATURE: TITLE: (DATE)

(OFFICIAL SEAL)

10

VERIFICATION OF "CLINICAL COMPETENCY" AS A NURSE PRACTITIONER I METHOD 3- EQUIVALENCY

Verification of the applicant's clinical competency in the delivery of primary health care is one of the requirements, which must be met in order to qualify to use the title "Nurse Practitioner" in California,

PRIMARY HEALTH CARE is that care which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease. (California Code of Regulations Section 1480(b)).

CLINICALLY COMPETENT means that one possesses and exercises that degree of learning, skill, care and experience ordinarily possessed and exercised by a member of the appropriate discipline In clinical practice. (California Code of Regulations Section 14BO(c)). The clinical experience must be such that the nurse received intensive experience in performing the diagnostic and treatment procedures essential to the provision of primary health care.

The verifying nurse practitioner and physician MUST meet the following requirements: 1. Current, clear and active licensure to practice. 2. i 3.

'·;-'

lB. 'TO BE COMPLf:'Fil~ BY THE EVALUATIISI$ ''llii·US:$;1l PRACTITIONER'1 The above applicant has applied for a nurse practitioner certification In California. Please provide the following Information and mall to the Board of Registered Nursing at the above address.

LAST NAME: FIRST NAME: MIDDLE NAME:

ADDRESS OF AGENCY: Number &. Street City State Postal/Zip Code

TELEPHONE NUMBER: SOCIAL SECURITY NUMBER:

DATES EMPLOYED IN SPECIALTY AREA: RN LICENSE NUMBER:

EXPIRATION DATE: From: To:

NP CERTIFICATION NUMBER: PROFESSIONAL SPECIALTY:

METHOD(S) UTILIZED TO EVALUATE APPLICANT'S CLINICAL COMPETENCY: PERIOD OF CLINICAL EVALUATION:

From: To: Month vaar Month Year

I certify under penalty of perjury that I have evaluated the above named applicant and verify that he{ she is clinically competent in the appropriate discipline in clinical practice in the provision of primary health care.

SIGNATURE OF EVALUATOR: DATE:

11

VERIFICATION OF "CLINICAL COMPETENCY" AS A NURSE PRACTITIONER

METHOD 3 ·EQUIVALENCY

Verification of the applicant's clinical competency in the delivery of primary health care is one of the requirements, which must be met in order to qualify to use the title "Nurse Practitioner" In California.

PRIMARY HEALTH CARE is that care which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease. (California Code of Regulations Section 1480(b)).

CLINICALLY COMPETENT means that one possesses and exercises that degree of learning, skill, care and experience ordinarily possessed and exercised by a member of the appropriate discipline In clinical practice. (California Code of Regulations Section 1480(c)). The clinical experience must be such that the nurse received intensive experience in performing the diagnostic and treatment procedures essential to the provision of primary health care.

lB. TO BE COM!PLETED BY THE EVALUATING "PHYStCIAN'1 The above applicant has applied for a nurse practitioner certiFication In California. Please provide the following information and mall to the Board of Registered Nursing at the above address.


ADDRESS OF AGENCY: Number &. Street City State Postal/Zip Code

TELEPHONE NUMBER: SOCIAL SECURITY NUMBER:

DATES EMPLOYED IN SPECIALTY AREA:

MD LICENSE NUMBER: From: To:

EXPIRATION DATE: PROFESSIONAL SPECIALTY:


From: To: Month Year Month Yaar

I certify under penalty of perjury that I have evaluated the above named applicant and verify that he/she is clinically competent in the appropriate discipline in clinical practice in the provision of primary health care.

SIGNATURE OF EVALUATOR: DATE:

12

VERIFICATION OF "CLINICAL EXPERIENCE" AS A NURSE PRACTITIONER

MEIHOD 3 • EQUIVALENCY Verification of the nurse's clinical experience in the delivery of primary health care is required in order for him/her to use the title "Nurse Practitioner" In California.

PRIMARY HEALTH CARE Is that care which occurs when a consumer makes contact with a health care provider who assumes responsibility and accountability for the continuity of health care regardless of the presence or absence of disease. (California Code of Regulations Section 1480(b)).

CLINICALLY COMPETENT means that one possesses and exercises that degree of learning, skill, care and experience ordinarily possessed and exercised by a member of the appropriate discipline In clinical practice. (California Code of Regulations Section 14BO(c)). The clinical experience must be such that the nurse received intensive experience in performing the diagnostic and treatment procedures essential to the provision of primary health care.

The verifying nurse practitioner and physician MUST meet the following requirements: 1. Current, clear and active licensure to practice. 2. Clinical competency In the orc>vis,ion 3. ob.se~vations of.:IJ:m•ic.ill,p•ra<~tlce.

··~~~~

The above applicant has applied for a nurse practitioner certification In California. Please provide the following Information and mall to the Board of Registered Nursing at the above address.

NAME OF AGENCY:

ADDRESS OF AGENCY: Number & Street City State Postal/Zip Code

NAME OF APPLICANT'S SUPERVISOR: SUPERVISOR'S TELEPHONE NUMBER:

SUPERVISOR'S TITLE: DATES OF SUPERVISOR'S EMPLOYMENT:

LICENSE NUMBER: From: To:

EXPIRATION DATE: SPECIAL TV AREA:

DATES OF SUPERVISED CLINICAL EXPERIENCE: NUMBER OF HOURS: CLICICAL SPECIALITY:

From: To: From: To: From: To:

I certify under penalty of perjury that I have verified that the above named applicant received the number of supervised clinical hours in the appropriate discipline in clinical practice in the performance of diagnostic and treatment procedures essential to the provision of primary health care.

SIGNATURE OF SUPERVISOR: DATE:

13

APPLICATION FOR TEMPORARY NURSE PRACTITIONER (NP) CERTIFICATE

INSTRUCTIONS:

1. The application fee for the Temporary Nurse Practitioner Certificate (TC/NP) is $30.00.

2. The TC/NP will not be issued until the California RN Endorsement Application and the Application for Nurse Practitioner Certification are complete with exception of criminal record clearance from the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI).

3. The TC/NP will not be mailed to an in-care-of address or a lhird party address.

4. Possession of a current and active California Temporary RN License (TL) is required.

PLEASE NQT~:)[YOU ALRE~J?YJ".Ql?.:?eSS A ~.EJ~IVIANENT CALif.ORI\IIA.RI\ILICENSE, '(.0,1,) ARE NOT ELIGIBLE FOR THE TEMPORA~Y Nl)R$1;pRACTI;T\QJ\I~~:~)~~TIFI(WA!fE (TG/Np) AND •t<:lW~/(P)'~l,ICATIOIIIsE!E ~OR THE TQ[NP WILL NOT BE .,.......... ·· .... .,. . .. ;: .. R"'F .... U.NDE"',:c:····· .. ·,·:c

~· .. . ~ .... , ~··

ffo Bij~MPLJ~~D B~~PPLICANlj .·'.: .. :.c: } :.;.l:.l.··· <·:""· ..... ,_, '• (PRINT OR r)iftEJ <' .. ,,·., ·!::-. ., C'· • •·

;~: : -.~< ,-,·.

LAST NAMEr ·· ·. > <.' .·.? FIRST-NAME: ::•.•;: ,: ::•:c::: ·.· MIDotiE NAME:7,:.

•••••

<;·.•.-<;:}-

'"

,•, <;:-.:; ;;.;' "• ' ·.·: ,·, ;;>

::• ·: ;:::·:·:·~-·:.>:>;",:::~;::::::_ ADDRESS:':· N~mber & Sjrt ;;·j;.:"' : , :c·· • D1>1TI'!'·g:Ji:''BIRTflj'(~onth!Day!Year) >-<' -,-,._, ,'

<·> ::/:, ·•· it}:;: ·' --.:;::::: -:·::::

. -···· '·'<·'"'-~ >' City < '.:•:>>:· .•. :··•·:.··· St~t~; Country ., : lol~t.11J~lP 0~\'le SOCIAL S'J;(,)URITV ,N\:I.Iii!IJ:~Jll''<jr

INDIVIDUAL TAXPAYER ID .NUMBER:

TELEPHONE NUMBER: PREVIOUS NAMES: (Including Maiden) MOTHER'S MAIDEN NAME: (Last Name Only) Home ( ) Alternate ( )

E-MAIL ADDRESS: TEMPORARY RN LICENSE NUMBER:

EXPIRATION DATE: NAME OF NURSE PRACTITIONER ACADEMIC PROGRAM:


TYPE OF PROGRAM:

D CERTIFICATE ENTRANCE DATE: D MASTERS (Month/Day/Year)

D POST-MASTERS COMPLETION DATE:

SPECIALTY: (Month/Day/Year)

I certify under penally of perjury that the above information regarding the Application for the Temporary Nurse Practitioner Certificate is true and correct.

SIGNATURE OF APPLICANT: DATE:

14

(Rev 03/13)

BUSINESS CONSUMER SEIWICE$_ AND HOUSIN0 AGENCY • OQVERNOR EDMUND G, Bf<OWN JR.

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov

OliPAI'nMIINT OF CONBLJMliA Af'fi\IAG

INFORMATION COLLECTION AND ACCESS

The Information Practices Act, Section 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals.

a me: BOARD OF REGISTERED NURSING

Telephone Number:

TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR SOCIAL SECURITY NUMBER WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USCA 405(c)(2)(C)) AUTHORIZE COLLECTION OF YOUR SOCIAL SECURITY NUMBER. IF YOU FAIL TO DISCLOSE YOUR SOCIAL SECURITY NUMBER, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON REQUEST IF AND WHEN

LICENSED.

Any known or foreseeable interagency or intergovernmental transfer which may be made of the information:

POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING SOCIAL SECURITY NUMBER TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE.

EACH INDIVIDUAL HAS THE RIGHT TO REVIEW THE FILES ON RECORDS MAINTAINED ON THEM BY THE AGENCY, UNLESS THE RECORDS ARE EXEMPT FROM DISCLOSURE.

MANDATORY REPORTER

Under California law each person licensed by the Board of Registered Nursing is a "Mandated Reporter" for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section 11166 and will comply with those provisions.

California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the Information concerning the incident.

Failure to comply with the requirements of Section 11166 is a misdemeanor, punishable by up to six months in a county jail, by a fine of one thousand dollars ($1 ,000), or by both imprisonment

(Rev lll/Ll) 2

BUSINE8$. CONSUMER SERVICES, AND IIOLJSINt;; AGEl-lei' • GOVERNOH EDMUr~o G. BROWN JR

BOARD OF REGISTERED NURSING

OEPARTMiiNT OF" OONSYMER 1\l'flAIRS PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov

INSTRUCTIONS FOR APPLYING FOR A NURSE PRACTITIONER FURNISHING NUMBER

Section 2836.3 of the Business and Professions Code requires that the Nurse Practitioner who wishes to furnish drugs and/or devices pursuant to Section 2836.1 have a California Board of Registered Nursing issued furnishing number. The number is renewable at the time of the applicant's Registered Nursing (RN) license renewal. To be eligible for the furnishing number, the California Board of Registered Nursing certified Nurse Practitioner must have completed a California Board of Registered Nursing approved advanced pharmacology course. The advanced pharmacology course must be completed at any nationally accredited master's or post-master's level academic Nurse Practitioner program. Continuing Education course(s) are not acceptable to meet the Nurse Practitioner Furnishing Number advanced pharmacology course requirement.

• A verification(s) of employment history which contains a minimum of five (5) years experience working as a Nurse Practitioner and prescribing/furnishing medication.

• A copy of your state license/certificate that allows you to prescribe/furnish medication as a Nurse Practitioner.

• A copy of your Drug Enforcement Agency (DEA) pocket identification card.

• A copy of that State's rules/regulations regarding prescriptive/furnishing authority for Nurse Practitioners.

• If applicable, a copy of the procedures/protocols/collaborative/practice agreement set in place by the supervising physician that allowed the Nurse Practitioner to use their prescriptive/furnishing authority in the state where they are licensed/certified.

Falsification of information on the application is a violation of the Nursing Practice Act and may result in not only denial of the issuance of the furnishing number, but also in Board disciplinary action against the applicant's registered nursing license.

Rev (10/2012)

HONORABLY DISCHARGED MEMBERS OF THE U.S. ARMED FORCES RECEIVE EXPEDITED REVIEW

Notwithstanding any other law, on and after July 1, 2016, a board within the department shall expedite, and may assist, the initial licensure process for an applicant who supplies satisfactory evidence to the board that the applicant has served as an active duty member of the Armed Forces of the United States and was honorably discharged (Business and Professions Code section 115.4.).

If you would like to be considered for this expedited review and process, please provide the following documentation with your application:

1. Report of Separation form.

The report of separation form issued in most recent years is the DO Form 214, Certificate of Release or Discharge from Active Duty. Before January 1, 1950, several similar forms were used by the military services, including the WD AGO 53, WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD and the NAVCG 553.

Information shown on the Report of Separation may include the service member's date and place of entry into active duty, date and place of release from active duty, last duty assignment and rank, military job specialty, military education, total creditable service, separation information, etc.

(Rev 07/2016)

m!311,ESS GOHSUMI:H SEI<VIGES ANIJ H(l\ISING 1\GI!NCY • GOVERNOR f::OMUND G. BROWN .m

c::lc:a BOARD OF REGISTERED NURSING PO Box944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

OI!PARTMENT OF OONBUMifR AFMIAS:

NURSE PRACTITIONER FURNISHING NUMBER APPLICATION

- MILITARY HONORABLE DISCHARGE~ Check here If you served as an active duty - member of the Armed Forces of the United States and were honorably discharged.

FIRST

BIRTH: (Month/Day/Year)

DEN NAME: (Last Name Only)

NAME

SCHOOL ADDRESS: Number City

I certify, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct.


•• SOCIAL SECURITY NUMBER/ITIN DISCLOSURE STATEMENT Disclosure of your social security number/ITIN is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA (c)(2)(C) authorizes collection of your social security number/ITIN. Your social security numberllTIN will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support In accordance with section 17520 of the Family Code, or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal wllh the requesting state. If you fall to disclose your social security number/ITIN, your application for Initial or renewal license wlll not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you .

. ev 07/2016)

m.oo;INESS CONSUMER SERVICES, fiND HOLJSINO AGI,NCY • <lOVH~NQH E:DMUNO t;_ GROWN JR

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov

OJlPAiltMENT OF CQN:'SUMilR 1\PF/\Jfll.f

NURSE PRACTITIONER ADVANCED PHARMACOLOGY COURSE VERIFICATION

In order to furnish drugs and/or devices pursuant to Business and Professions Code, Section 2836.1, the Nurse Practitioner must complete a California Board of Registered Nursing approved advanced pharmacology course. The criteria for the advanced pharmacology course is listed on the two (2) page attachment.

FIRST

State

mall

ADDRESS: Number & Street City State Zip Code

ADVANCED PHARMACOLOGY COURSE/CONTENT:

Entrance and completion dates for course: Entrance: Completion: (Month/Day/Year) (Month/Day/Year)

Was a separate course?D D If YES, specify the course title:-----,--,-----;=,---,=;--If NO, was integrated in the program curriculum? D D YES NO

YES NO

Equivalent to: 3 semester units: D D 5 quarter units: D D 45 hours: D D YES NO YES NO YES NO

The drugs or devices are furnished or ordered by a Nurse Practitioner in accordance with standardized procedures or protocols developed when the drugs or devices furnished or ordered are consistent with the practitioner's educational preparation or for which clinical competency has been established and maintained. D 0

YES NO The Advanced Pharmacology course includes the key points and course objectives listed on the two (2) page attachment. D D

YES NO

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and Correct.

SIGNATURE: ____________________________ __ -==,..---TITLE: ______ _ (DATE)

BUSINESS. CONSUMER SEf!VICE.~. AND fiQ\ISI~¥3 AGE'ICY • t..\OVERNOR EDMUND G. SHOWN JR

c:Jca BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

OliPARTMENT Of' OCNS:I.IMilR AFMIFW

NURSE PRACTITIONER ADVANCED PHARMACOLOGY COURSE FOR FURNISHING

These revised guidelines are established for Nurse Practitioner programs who offer advanced pharmacology courses in order to meet Furnishing requirements.

MINIMUM COURSE OFFERINGS • A post-RN licensure advanced pharmacology course based on the RN's previous knowledge of

pharmacology and pharmacotherapeutics. • A three (3) semester units or five (5) quarter units academic course.

KEY POINTS: The advanced pharmacology course must include: • The mechanism for ongoing communication between the student and course instructor .

. . . ! ..... The requirem>:l'ts (91: .(tpprove~l sJ\llJ<Jardized proce41!res .to. be in place pt:ior to beginnil)g practice.

:%lf•Hii~~.require~~'#\f:miMHish dh~J#l~i~~~.s pursuW,H¢t~r@dardized ~~pp~dure. : \•::~ • Th~:jitrnish}~B responsibilit)(iX6r Sched~le II, tl~<IV, V controlled ~J\~s@:ces that a~~.to be furnished : wi~~·~ pa~ie\)~fspecific p~·o:~~~) in com~)j~nce tf:\fh Health and Safe,~C~M. section ll/900 for NPs. '·: • The furmslt1ng responstbthtf• for Sch~qjjle lt{::'IU, IV and V co.tltfolle:\l;:;substanc~.~;:that are to be • furtiished ~itli 11 p(lt\l'nt sp~~ific profWbl in .~iimplian~e with t:t~~lth '~%'t;I Safe~i¢:ode 11056 for •;y )§tJMs. ·c;:,i'ii (':' }(' ' i\: }(' t'~ '·~ .} • 't'~~Pharmlj¢y Rules and R<!@latiO'ns for NPs;al)d CNMs, Hea!tK&; ~.~f~i')i;Codes~~d OBRA 1990 ~; S~~\ion 483~~9, Federal Regi~~~r. 0 ,( ) · ~;

i;;l• f0~~l~~~Bd1~.~~~\~6tainea~itrom the healtti~(~~~~*~i#~* oJ~i,e client Ji~enti~\~·~r::~R~i'~priate . thenipeutic regimen, including drugs and/or devices" .. ' . ·.· . . .

2. Uses knowledge of pharmacokinetics when developing a therapeutic regimen that maximizes the therapeutic effectiveness while minimizing adverse reactions.

3. Uses knowledge of pharmacodynamics to observe the effects of drugs and/or devices on a client; to predict the client's response; and to understand the effects of the drugs and/or devices.

4. Evaluates the response and compliance of the client to the drugs and/or devices and implement appropriate action.

5. Provides appropriate client education regarding the furnished drugs and/or devices. 6. Furnishes drugs and/or devices pursuant to standardized procedures and in conformance with

applicable laws, codes and/or regulations. Includes knowledge of Pharmacy rules and regulations, Health & Safety Code and Federal Register.

7. Examines appropriate guidelines for the pharmacological management of selected health care syndromes/diseases commonly encountered with awareness of client's nutrition, culture, ethnicity and socioeconomic status.

8. Uses knowledge and awareness of the role of herbal and natural remedies while treating disease states.

Advanced Pharmacology Enabling Objectives have been developed through public input and are available upon request.

FACULTY QUALIFICATIONS All stated qualifications must be met by the faculty, include Directors and instructors. • Current, valid and clear license to practice in the appropriate discipline. • Demonstrates expertise in the theoretical and clinical aspects of pharmacology/pharmacotherapeutics. • Possesses at least two years of experience in the teaching of advanced pharmacology. • Includes a faculty member who has completed a doctoral level pharmacology/pharmacotherapeutics

degree. • Demonstrates evidence of advanced clinical practice within the past five years applying the principles of

advanced pharmacology.

ADVANCED PHARMACOLOGY ENABLING OBJECTIVES

•

• • • • •

Defines and verbalizes an understanding of the terminology of advanced pharmacology. (Vocabulary list to be included) Identifies sources of drugs and provides examples of drugs from each drug source . Describes the "targets" of drugs . Describes the pharmacokinetic process of absorption, distribution, metabolism, and excretion . Identifies factors that alter the processes of absorption, distribution, metabolism, and excretion . Analyzes how the body's acid base environment affects the pharmacokinetic process of absorption,

••·•· :di~tribution, l)l:l\\ti\\Joli~J::and e~eth>n:9:f drugs. < · :· •'~'' ~::,l; ~.i i Desttibes vatf~~~~~"lYi'rt~'deterni'~~·hf6•8i)r)'ect dos~j)es ofdi'Ligs. '' ':: ~,~, ' ~ DetJh~s half-)j;f~ and explains t~~;import~¥~ of a <lmg's half-life in a th$f~Mtitic drug re~jijien. ':f• Des$hbes fa~tu'fs that influenc'*:~:drug's nMf:,life. ,, ·' : ·~e·. :;i

:;, • An~j92:es theW~~ationship betw~¥~ drugs (i@their@iysiological and p~t~oph~#0logical r~~ponses. • ••• y~~~rstands ~.~t~~.acoki1~ic an~~·~~armao.~dyi1al)li\l :effects .~~· broa\1. categori~p' pf dmgs, i.e.,

ar\tiblOtics, a1J,~l:;Ll'fh)ltfiliiics, antmyl)¢rt~,I'j~lves con1racephves; etc. us~~.m spec1ti~ treatm~J)\ regimens, Uses data o$tained during a C;\hifit•s 'H&P to iifel)tify appropria~:drug choi#~/s andi!l!¢rbs, vitamins, minerals, ano trace elements r~imen/s, and rec~hizes the role .§Mei:\J~t~ff\Wraturafremedies in the

• • •

• • •

•

•

• •

•

treatment of health and disease•:st~tes. :•'••: ··:··· : . .. Based upon •. !he . pl:iJ)Cii;lles qf pharmacokineti~~.!\1,'19 .,p.l:lllJma~?¢ynamics, id~~tifies''the. iQ.dj£~tions, ratioi}ale, and11ledh\lfil$11). of act\Qh for drugs and ~r/~'Dil\l§j~i:~t.l'Jgs 1i~~d to treat speo:i,fj~ cm11i)itipi)~;, .•. : Under~tands the poiential interactions between dr~gs"iind he~t;s, vitamins, minerals;·;;nd trace.eienie~ts . Performs appropriate monitoring before, during, and after specific drug regimens . Monitors efficacy of drugls evaluates the response and compliance of the client to the drugs/devices and provides interventions for side effects, and manages adverse events that may occur. Identifies drugs with narrow therapeutic range . Identifies appropriate methods to write and transmit prescriptions . Furnishes drugs pursuant to legal requirements, standardized procedures, ethical standards, and in compliance with health and safety codes. Identifies resources for drug information and uses the resources to maintain clinical competency for furnishing. Describes the essential components of client education re: medications including: name of medication/s frequency/time of doses, correct dosage/s to take, how to take the medication/s i.e., with or without food, what to do if a dose of a medication is missed, side effects to expect, and adverse event/s to report to the prescriber. Identifies factors that influence medication compliance . Provides comprehensive and appropriate client and family education re: drugs of choice and alternatives and involves the client and family in the decision making process re: drug treatments. Chooses most appropriate drug for a disease base upon client's symptomatology, health status, and lifestyle.

!JllSINESS. CONSUMER SEnVICES, AND IIQUS!N(O AGENl'.Y • GOVERCJOf< EDMIJND G_ BROWN JR

0 !i:PARTMIINT OF CONBUMER AFFAiflU

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.qov

Clc:a



(R~'·Ol/ll}

Agency BOARD OF REGISTERED NURSING

Number:

to

TO DETERMINE ELIGIBILITY FOR URE. YOUR SOCIAL NU WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USCA 405(c)(2)(C)) AUTHORIZE COLLECTION OF YOUR SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TO DISCLOSE YOUR SOCIAL SECURITY NUMBERIITIN, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON

EST IF AND WHEN U BECOME LICENSED.


POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING SOCIAL SECURITY NUMBERIITIN TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE.


MANDATORY REPORTER

Under California law each person licensed by the Board of Registered Nursing is a "Mandated Reporter" for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section 11166 and will comply with those provisions. ·

California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies) whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the information concerning the Incident.

(1\ev lll/ll) 2

8 TAT8 o• C A L IIIOANIA BUSINESS, <X>NSUMER SERVICES. AND .. lOUSING AGEI¥;V • GOVERNOR EOMUI~O G. BROHH JR.

~ • c:1c a BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100

DEPARTMEN T OF CONSU MER AFFAIRS P (916) 322-3350 F (916) 574-8637 I www.rn.ca.qov

APPLICATION FOR NURSE PRACTITIONER (NP) CERTIFICATION

APPLICATION FEE- $500.00

0 MILITARY HONORABLE DISCHARGE- Check here if you served as an active duty member of the Armed Forces of the United States and were honorably discharged.

PERSONAL DATA ( PRINT OR TYPE)


ADDRESS: Number and Street

City State Country Postal/Zip Code

HOME TELEPHONE NUMBER: ALTERNATE TELEPHONE NUMBER: E-MAIL ADDRESS:

( ) ( ) DATE OF BIRTH: U.S. SOCIAL SECURITY NUMBER PREVIOUS NAMES: (Including Maiden) MOTHER' S MAIDEN NAME: (Month/Day/Year) OR INDIVIDUAL TAXPAYER ID (Last Name Only)

NUMBER:

RN L:.ICENSURE/NURSE PRACTITIONER CERTIFICATI ON

California RN License Number: - -:------- --

./' Date Issued: ----'.,: _______ _

Expiration Date: ---------

List .8..1J...States Where You Hold/Held an RN License and Status:

List ALJ.._States Where You Hold/Held a Nurse practitioner License/Certjfjcate and Status:

.·

RN EDUCATION

Name of Professional Registered Nursing Program

City State Country

TYPE OF PROGRAM:

0 ASSOCIATE DEGREE D DIPLOMA 0 BACCALAUREATE DEGREE D MASTERS DEGREE/NURSING

Entrance Date: --------

Graduation/Completion Date:---------

NURSE PRACTITIONER EDUCATI ON

Name of Nurse Practitioner Academic Program

City State Country

Area of Specialization:

{Rev. 0312018)

TYPE OF NURSE PRACTITIONER ACADEMIC PROGRAM:

0 CERTIFICATE D MASTERS D POST-MASTERS

Entrance Date:

Graduation/Completion Date: --------

(Questions on both sides of page)

NAME OF APPLICANT:

NURSE PRACTITIONER PROFESSIONAL CERTIFICATION (If Applicable):

Name of Organization/Association METHOD OF CERTIFICATION:

0 EXAMINATION

Area of Specialization: D OTHER (Please Explain):

Original Date of Certification: --------

Certification Number: Current Recertification Cycle Dates: ---------

BACKGROUND INFORMATION

Have you applied for a Nurse Practitioner certificate in California? If yes, name on previous application:

Date Submitted:

D YES

::.::: •.·, ·/:·

D NO

D NO

D NO

D NO

I understand that I am required to report immediately to the California Board of Registered Nursing if I am convicted of ANY offense that occurs between the date of this application and the date that a California registered nurse license is issued. I am also required to report to the California Board of Registered Nursing any disciplinary action and/or voluntary surrender against ANY health-care related license/certificate that occurs between the date of this application and the date that a California registered nurse license is issued. I understand that failure to do so may result in denial of this application or subsequent disciplinary action against my license/certificate.

I certify, under penalty of perjury under the laws of the State of California, that all information provided in connection with this application for licensure is true, correct and complete. Providing false information or omitting required information is grounds for denial of licensure or license revocation in California.

SIGNATURE OF APPLICANT DATE

"U.S. SOCIAL SECURITY NUMBER/ITIN DISCLOSURE STATEMENT

Attach a recent 2"x2" passport type photograph.

Please tape on all four sides.

Head and shoulders only

Disdosure of your U.S. Social Security Number/ITIN Is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USC section 405(c)(2)(C)) authorizes collection of your U.S. Social Security Number/ITIN. Your U.S. Social Security Number/ITIN will be used exclusively for tax enforooment purposes and for purposes of compliance with any judgment or order lor family support In accordance with section 17520 of the Family Code, or for verification of licensure or examinalion status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. II you fail to disdose your U.S. Social Security Number/ITIN, your applicalion lor lnilial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.

(Re~. OOJ201fl)

2

8 T AT. O P CAL I JI'OANIA 9USINE:SS. CONSUMER SERVICES. AI~O HOUSit.r; AGEt.K:Y • GOVERNOR EDMU~JD G BROW:~ JR

DEPARTMENT OF CONSUMER AFFAIRS

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100

c:1c:a P (916) 322-3350 F (916) 574-8637 I www.rn.ca.qov

VERIFICATION OF NURSE PRACTITIONER ACADEMIC PROGRAM

TO BE COMPLETED BY APPLICANT: Please complete Section A and forward to the program director/representative for the nurse practitioner academic program for completion. Official transcripts submitted must include all completed coursework with the certificate/degree status conferred and must be sent directly to the Board of Registered Nursing by the Registrar's Office/Transcript Office. A processing fee may be required for the submission of the off icial transcripts.

jA. TO BE COMPLETED BY APPLICANT ! (PRINT OR TYPE}


ADDRESS: Number & Street DATE OF BIRTH: (Month/Day/Year)

City State Country Postal/Zip Code U.S. SOCIAL SECURITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:


E-MAIL ADDRESS: CALIFORNIA RN LICENSE NUMBER: ·=

': .. :: EXPIRATION DATE:

NAME OF ACADEMIC PROGRAM:

'\~/ SPECIALTY:

·::: ·,·


B. TO BE COMPLETED BY THE PROGRAM DIRECTOR/REPRESENTATIVE FOR THE;NURSE

PRACTITIONER ACADEMIC PROGRAM The above applicant has applied for a nurse practitioner certificat ion in California. Please provide t he following informat ion and mail t o the Board of Registered Nursing at the above address.

NAME OF NURSE PRACTITIONER ACADEMIC PROGRAM: TELEPHONE NUMBER: ( )


TYPE OF PROGRAM: Entrance Date:

D CERTIFICATE (Month/Day/Year)

D MASTERS Completion Date: D POST-MASTERS (Month/Day/Year)

SPECIALTY: Date Certificate/Degree Status Conferred: {Month/Dav!Year)

OUT OF STATE NP ACADEMIC PROGRAM GRADUATES: Recognized by Commission on Collegiate Nursing Education: D D

YES NO If yes, Name: Program Approval Cycle Dates:

I certify under penalty of perjury that the documentation rega rding the completion of the nurse practitioner academic program for the above named applicant is true and correct.

SIGNATURE: __________________________________ __ ___________ TITLE: ________________ _ ( DATE)

(Rev 0312018) 3

l

BUSINESS, CONSUMER SERVICES. AND HOUSING AGENCY • GOVERNOR EDMUND G BROWN JR

o c a BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov


VERIFICATION OF NURSE PRACTITIONER CERTIFICATION BY NATIONAL ORGANIZATION/ ASSOCIATION

METHOD 2 TO BE COMPLETED BY APPLICANT: Please complete Section A and submit to the applicable national organization/association to verify your nursing practitioner certification status. A fee is required by the national organization/association lor the processing of the verification form.

jA. TO BE COMPLETED BY APPLICANT! (PRINT OR TYPE)



City State Country Postal/Zip Code U.S. SOCIAL SECURITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:

TELEPHONE NUMBER: PREVIOUS NAMES: (Including Maiden) MOTHER'S MAIDEN NAME: (Last Name Only) Home ( ) Alternate ( ) .· E-MAIL ADDRESS: :,

CALIFORNIA RN LICENSE NUMBER:

EXPIRATION DATE:

NAME OF ACADEMIC PROGRAM: SPECIALTY:

·: .. ·:


is. TO BE COMPLETED BY THE CERTIFYING ~ATIONAL ORGANIZATION/ ASSOCIATION j The above applicant has appl ied for a nurse practitioner certification in Cal ifornia. Please provide the following information and mail to the Board of Registered Nursing at the above address.

NAME OF CERTIFYING NATIONAL ORGANIZATION/ASSOCIATION TELEPHONE NUMBER: ( )


METHOD OF CERTIFICATION: CERTIFICATE NUMBER: ORIGINAL DATE OF CERTIFICATION:

NURSE PRACTITIONER SPECIALTY AREA:

CURRENT RENEWAL CYCLE DATES FOR CERTIFICATION/RECERTIFICATION: (If not applicable, please explain)

From: To: ( Month/Year Month/Year

I certify under penalty of perjury that the documentation regarding the nurse practitioner certification status for the above named applicant is true and correct.

SIGNATURE: TITLE: ( DATE)

(OFFICIAL SEAL)

(A"". 0312018)

4

l

. T ATiil o.- CALI .. ORNIA BUSINESS. CONSUMER SERVICES. AND HOUSING AGENCY • GOVERNOR EDMUt.IO G BROWt.,. JR

c:1c a BOARD OF REGISTERED NURSING

DEPARTMENT OF CONSUMER AFFAIRS PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.qov

VERIFICATION OF "CLINICAL COMPETENCY" AS A NURSE PRACTITIONER

METHOD 3 - EQUIVALENCY

Verification of the applicant's clinical competency in the delivery of primary care is one of the requirements, which must be met in order to qualify to use the title "Nurse Practitioner'' in California.

PRIMARY CARE means comprehensive and continuous care provided to patients, families, and the community. Primary care focuses on basic preventative care, health promotion, disease prevention, health maintenance, patient education and the diagnoses and treatment of acute and chronic illnesses in a variety of practice settings. (California Code of Regulations Section 1480(b)).

CLINICALLY COMPETENT means the individual possesses and exercises the degree of learning, skill, care and experience ordinarily possessed and exercised by a certified nurse practitioner providing healthcare in the same nurse practitioner category. The clinical experience must be such that the nurse received intensive experience in performing the diagnostic and treatment procedures essential to the provision of primary care. (California Code of Regulations Section 1480(c)).

The verifying nurse practitioner and physician MUST meet the following requirements: 1. Current, clear and active licensure to practice. 2. Clinical competency in the provision of primary care. 3. Direct observations of clinical practice.

!A. TO BE COMPLETED BY APPLICAJ'!4T I (PRINT OR TYPE)

LAST NAME: FIRST NAME: :: MIDDLE NAME:

U.S. SOCIAL SECURITY NUMBER or DATE OF BIRTH: (Month/Day/Year) CALIFORNIA RN LICENSE NUMBER: INDIVIDUAL TAXPAYER ID NUMBER:

.· ;;_

I SIGNATURE OF APPLICA NT: ______________________ DATE: ------

•

Is. TO BE coMPLETED BY THE EVALUATING "NURSE PRACTITIONER" I The above applicant has applied for a nurse practit ioner certification in California. Please provide the fol lowing information and mail to the Board of Registered Nursing at the above address.



TELEPHONE NUMBER: U.S. SOCIAL SECURITY NUMBER:

DATES EMPLOYED IN SPECIALTY AREA: RN LICENSE NUMBER:

EXPIRATION DATE: From: To:

NP CERTIFICATION NUMBER: PROFESSIONAL SPECIALTY:

METHOD(S} UTILIZED TO EVALUATE APPLICANT' S CLINICAL COMPETENCY: PERIOD OF CLINICAL EVALUATION:

From: To: (Month/Year) Month/ Year

I certify under penalty of perjury that I have evaluated the above named applicant and verify that he/she is clinically competent in the appropriate discipline in clinical practice in the provision of primary care.

SIGNATURE OF EVALUATOR: ______________________ DATE: ------

(Rev 03/20 18) 5

. T AT• 0 .. CA\.I JI ORNI A BUSINESS. CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G BRO\.Vt l JR


BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.qov

c:Jc a

VERIFICATION OF " CLINICAL COMPETENCY" AS A NURSE PRACTITIONER

METHOD 3 - EQUIVALENCY

Verification of the applicant's clin ical competency in the delivery of primary care is one of the requirements, which must be met in order to qualify to use the title "Nurse Practitioner'' in California.


CLINICALLY COMPETENT means the individual possesses and exercises the degree of learning, skill , care and experience ordinarily possessed and exercised by a certified nurse practitioner providing healthcare in the same nurse practitioner category. The clinical experience must be such that the nurse received intensive experience in performing the diagnostic and treatment procedures essential to the provision of primary care. (California Code of Regulations Section 14BO(c)).

The verifying nurse practitioner and physician MUST meet the following requirements: 1. Current, clear and active licensure to practice. 2. Clinical competency in the provision of primary care. 3. Direct observations of clinical pract ice.

lA. TO B.~ COMPLETED BY APPLICANT! _(pRINT OR TYPE)



I S I GNATURE OF APPLICANT: _ _ ___ ______ -:-:-:-__________ DATE: - -----

JB. TO BE COMPLETED BY TH~ EVALUATING "PHYSICIAN" J The above applicant has applied for a nurse practitioner certification in California. Please provide the following information and mail to the Board of Registered Nursing at the above address.



TELEPHONE NUMBER: U.S. SOCI AL SECURITY NUMBER:

DATES EMPLOYED IN SPECIALTY AREA:

MD LICENSE NUMBER: From: To:

EXPIRATION DATE: PROFESSIONAL SPECIALTY:


From: To: ( Month/ Year ( Mont h/Year)

I certify under penalty of perjury that I have evaluated the above named applicant and verify that he/she is clinically competent in the appropriate discipline in c linical practice i n the provision of primary care.

SIGNATUREOFEVALUATOR: ______________________ DATE: _____ _

(Rev. 03/2018) 6

•TAT. 0 .. CAL i f' O ANIA BUSINESS, CONSUMER SERVICES. AND HOUSING AGEt.tCY • GOVERNOR EOMJNO G- BROWN JR

DEPAR TMEN T OF CONSUMER AFFAIRS

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.qov

c::1c a

VERIFICATION OF "CLINICAL EXPERIENCE" AS A NURSE PRACTITIONER

METHOD 3 - EQUIVALENCY Verification of the nurse's clinical experience in the delivery of primary care is required in order for him/her to use the title "Nurse Practitioner" in California.


CLINICALLY COMPETENT means the individual possesses and exercises the degree of learning, skill, care and experience ordinarily possessed and exercised by a certified nurse practitioner providing healthcare in the same nurse practitioner category. The clinical experience must be such that the nurse received intensive experience in pertorming the diagnostic and treatment procedures essential to the provision of primary care. (California Code of Regulations Section 1480(c)).

The verifying nurse practitioner and physician MUST meet the following requirements: 1. Current, clear and active licensure to practice. 2. Clinical competency in the provision of primary care. 3. Direct observations of clinical practice.

JA. TO BE COMP.:lETED BY APPLICANT ! _If'RINT OR TYPE)



;:

I ~IGNATURE OF APPLICANT'---------. -0----;.-.¢-, --------DATE: -. -, -----j B. TO BE COMPLETED BY THE PHYSICIAN/NURSE PRACTITIONER VERIFYING THE APPLICANT'S

LINICAL EXPERIENCE The above applicant has applied for a nurse practit ioner certification in California. Please provide the following information and mail to the Board of Registered Nursing at the above address.

NAME OF AGENCY:


NAME OF APPLICANT'S SUPERVISOR: SUPERVISOR'S TELEPHONE NUMBER:

SUPERVISOR'S TITLE: DATES OF SUPERVISOR'S EMPLOYMENT:

LICENSE NUMBER: From: To:

EXPIRATION DATE: SPECIALTY AREA:

DATES OF SUPERVISED CLINICAL EXPERIENCE: NUMBER OF HOURS: CLINICAL SPECIALITY:

From: To: From: To: From: To:

I certify under penalty of perjury that I have verified that the above named applicant received the number of supervised clinical hours in the appropriate discipline in clinical practice in the performance of diagnostic and treatment procedures essential to the provision of primary care.

SIGNATURE OF SUPERVISOR: DATE: _______ _

(Rev. 03/20 18) 7

eTAT 8 Of' CALIIIOAN I A BUSINESS, CONSL.It-AER SER'ACES, AIID t-OUSit~ AGENCY • GOVEAt.IOfl EOMUtiO G. BRCN.JN JR

c:1c:a BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov




Agency Name: BOARD OF REGISTERED NURSING

Title of official responsible for information maintenance:

EXECUTIVE OFFICER

Address: Telephone Number:

P.O. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350

Authority which authorizes the maintenance of the information:

SECTION 30, SECTION 2732.1 (a), BUSINESS AND PROFESSIONS CODE ::;

ALL INFORMATION IS MANDATORY.

The consequences, if any of not providing all or any part of the requested information:

FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE APPLICATION BEING REJECTED AS INCOMPLETE-

The principal purpose(s) for which the information is to be used:

TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBER/ITIN WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USC section 405(c)(2)(C)) AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TO DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER/ITIN, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENAL TV AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON REQUEST IF AND WHEN YOU BECOME LICENSED.


POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING U.S. SOCIAL SECURITY NUMBERIITIN TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE.


(Rev. 03nOI &) 8

MANDATORY REPORTER

Under California law each person licensed by the Board of Registered Nursing Is a "Mandated Reporter" for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Penal Code Section 11166 and will comply with those provisions.

California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the information concerning the Incident.

(Rev. (13/201&) 9

.TAT• 0 fll CALI .. ORNIA BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G BROWN J R._

c:lc::a BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100

DEPARTMENT OF CONSUMER AFFAIRS P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov

APPLICATION FOR TEMPORARY NURSE PRACTITIONER (NP) CERTIFICATE

INSTRUCTIONS:

1. The application fee for the Temporary Nurse Practitioner Certificate (TC/NP) is $150.00.

2. The TC/NP will not be issued until the Application for Nurse Practitioner Certification is complete with exception of criminal record clearance from the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI).

3. The TC/NP will not be mailed to an in-care-of address or a third party address.

4. Possession of a current and active California Temporary AN License (TL) is required.

PLEASE NOTE: IF YOU ALREADY POSSESS A PERMANENT CALIFORNIA AN LICENSE, YOU ARE NOT ELIGIBLE FOR THE TEMPORARY NURSE PRACTITIONER CERTIFICATE (TC/NP) AND YOUR APPLICATION FEE FOR THE TC/NP WILL NOT BE REFUNDED.

tfo BE COMPLETED BY APPLICANT!

(PRINT OR TYPE)


: ... ·.· ADDRESS: Number & Street ·: :·, DATE OF BIRTH: (Month/Day/Year)

::

City State Country Postal/Zip Code U.S. SOCIAL SECUR.ITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:


E-MAIL ADDRESS: TEMPORARY AN LICENSE NUMBER:

EXPIRATION DATE:

NAME OF NURSE PRACTITIONER ACADEMIC PROGRAM:


TYPE OF PROGRAM:

0 CERTIFICATE ENTRANCE DATE: 0 MASTERS (Month/Day/Year)

D POST-MASTERS COMPLETION DATE:

SPECIALTY: (Month/Day/Year)

I certify under penalty of perjury that the above information regarding the Application for the Temporary Nurse Practitioner Certificate is true and correct.


(Rev. 03/2018)

eTAT8 O fl CAL I .. OAN I A BUSINESS, CONSUMER SERVICES. AND HOUSING AGENCY • GOVERNOR EOMUNO G BROVVN JR

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100

c c a DEPARTMENT OF CONSUMER AFFIUAS

P (91 6) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

(Rev 0312018)


The Information Practices Act, Section 1798.17 Civi l Code, requires the following information to be provided when collecting information from individuals.



EXECUTIVE OFFICER


P.O. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350

Authority wh ich authorizes the maintenance of the information:

SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODE .•:•:



FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE APPLICATION BEING REJECTED AS INCOMPLETE.

The principal purpose(s) for which the information is to be used: ·.·

TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBERIITIN WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USC 405(c)(2)(C)) AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBERIITIN. IF YOU FAIL TO DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBERIITIN, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON REQUEST IF AND WHEN YOU BECOME LICENSED.


POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING U.S. SOCIAL SECURITY NUMBERIITIN TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE.


2

MANDATORY REPORTER

Under California law each person licensed by the Board of Registered Nursing is a "Mandated Reporter" for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Penal Code Section 11166 and will comply with those provisions.

California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies) whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the information concerning the incident.

(Rev 0312018) 3

8TA T e O fl CAL t fiOAN I A BUSINESS, CONSUMER SERvtCES, AND HOUSING AGENCY • GOVERNOR EDMUND G BRONN JR

BOARD OF REGISTERED NURSING PO Box 94421 0, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov

o c:::a DEPARTMENT OF CONSUMER AFFAIRS

NURSE PRACTITIONER FURNISHING NUMBER APPLICATION

APPLICATION FEE - $400.00

I 0 MILITARY HONORABLE DISCHARGE- Check here if you served as an active duty member of the Armed Forces of the United States and were honorably discharged.

PERSONAL DATA (PRINT OR TYPE)



City State Country Zip Code U.S. SOCIAL SECURITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:••

TELEPHONE NUMBER: PREVIOUS NAMES: (Including Maiden) MOTHER'S MAIDEN NAME: (Last Name Only) Home ( )

Alternate ( )

CA RN LICENSE NUMBER: CA NP NUMBER: NP SPECIALTY:

::

NU RSE PRACTITIO f'4ER ADVANCED PHA~.~.ACO ... QGV: ~Q.URSE \

NAME OF NURSE PRACTITIONER PROGRAM COURSE TITLE: COMPLETION DATE: # QTRISEM UNITS:

NAME OF ACADEMIC COURSE:

SCHOOL ADDRESS: Number & Street City State Zip Code

I certify, under penalty of perjury under t he laws of the State of California, that t he foregoing is true and correct.

S I GNATURE OF APPLICANT: ______________________ DATE: _____ _

** U.S. SOCIAL SECURITY NUMBERIITIN DISCLOSURE STATEMENT Disclosure of your U.S. Social Security Number/ITIN is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USC section 405(c)(2)(C)) authorizes collection of your U.S. Social Security Number/ITIN. Your U.S. Social Security Number/ITIN will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination status by a l icensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your U.S. Social Security Number/ITIN, your application for initial or renewal license will not be processed and you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.

(Rev. 03/2016) 1

•TATU 0" CAL I ,.OQNIA BUSif~SS. C.OUSUMEA SEAVIGES. AI-D fOJSitMJ AGPJC'/ • GOVERt¥JR EIJtAIJtiD G Bflt.)'N;l JR.

@ . -

; c::1c a BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca .gov

DEPARTMENT OF CONSUM ER AFFAIRS

NURSE PRACTITIONER ADVANCED PHARMACOLOGY COURSE VERIFICATION

In order to furnish drugs and/or devices pursuant to Business and Professions Code, Section 2836.1, the Nurse Practitioner must complete a California Board of Registered Nursing approved advanced pharmacology course. The criteria for the advanced pharmacology course is listed on the two (2) page attachment.

tfo BE coMPLETED BY APPLICANT I {PRINT OR TYPE)



City 1 State [ Country [ Zip Code U.S. SOCIAL SECURITY NUMBER or INDIVIDUAL TAXPAYER ID NUMBER:


CALIFORNIA RN LICENSE I CA NP NUMBER: I DATES COURSE WAS TAKEN: NUMBER:

::·;

SIGNATURE OF APPLICANT: ___________________ DATE:------

0 BE COMPLETED BY THE DIRECTOR OF THE NURSE PRACTITIONER CA DEMIC PROGRAM

The above applicant has applied for a Nurse Practitioner furnishing number in California. Please provide the following information and mail to the California Board of Registered Nursing at the above address. The criteria for the advanced pharmacology course is listed on the two (2) page attachment.

NAME OF NURSE PRACTITIONER PROGRAM: TELEPHONE NUMBER:

ADDRESS: Number & Street City State Zip Code

ADVANCED PHARMACOLOGY COURSE/CONTENT:

Entrance and completion dates for course: Entrance: Completion:

Was a separate course? 0 0 (Month/ Day/Year) (Month/ Day/Year)

If YES, specify the course title: YES NO If NO, was integrated in the program curriculum? 0 0

YES NO

Equivalent to: 3 semester units: 0 0 5 quarter units: 0 0 45 hours: 0 0 YES NO YES NO YES NO

The drugs or devices are furnished or ordered by a Nurse Practitioner in accordance w ith standardized procedures or protocols developed when the drugs or devices furnished or ordered are consistent with the practitioner's educational preparation or for which clinical competency has been established and maintained. 0 0

YES NO The Advanced Pharmacology course includes the key points and course objectives listed on the two (2) page attachment. 0 0

YES NO

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and Correct.

SIGNATURE: ______________________________ _ TITLE: _____ _ (DATE)

(Rev. 03/2018) 2

.TAT8 a .. CAL I IIOQN I A BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G BRONN JR

BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 1 www.rn.ca.gov


(Rev. 0312018)

NURSE PRACTITIONER ADVANCED PHARMACOLOGY COURSE FOR FURNISIDNG

These revised guidelines are established for Nurse Practitioner programs who offer advanced pharmacology courses in order to meet Furnishing requirements.

MINIMUM COURSE OFFERINGS • A post-RN licensure advanced pharmacology course based on the RN's previous knowledge of

pharmacology and pharmacotherapeutics. • A three (3) semester units or five (5) qumter units academic course.

KEY POINTS: The advanced pharmacology course must include: • The mechanism for ongoing communication between the student and course instructor. • The requirements for approved standardized procedures to be in place prior to beginning practice. • The requirement to furnish drugs/devices pursuant to a standardized procedure. • The furni shing responsibility for Schedule II, ill, IV, V controlled substances that are to be furnished

with a patient-specific protocol in compliance with the Health and Safety Code (HSC) Division 10, Uniform Controlled Substances Act, Sections II 000-11651 , Chapter I. General Provis ions and Definitions, for Nurse Practitioners.

• The furnishing responsibility for Schedule n, III, IV and V controlled substance~. that are to be furnished with a patient specific protocol in compliance with Health and Safety Code (HSC) Division 10, Uniform Controlled Substances Act, Section 11056, for Cettified Nurse Midwives.

COURSE OBJECTIVES: 1. Uses the data base obtained from the health assessment of the client to identify an appropriate

therapeutic regimen, including drugs and/or devices 2. Uses knowledge of pharmacokinetics when developing a therapeutic regimen that maximizes the

therapeutic effectiveness while minimizing adverse reactions. 3. Uses knowledge of pharmacodynamics to observe the effects of drugs and/or devices on a client; to

predict the client's response; and to understand the effects of the drugs and/or devices. 4. Evaluates the response and compliance of the client to the drugs and/or devices and implement

appropriate action. 5. Provides appropriate client education regarding the furnished drugs and/or devices. 6. Fumishes drugs and/or devices pursuant to standardized procedures and in conformance with

applicable laws, codes and/or regulations. 7. Examines appropriate guidelines for the pharmacological management of selected health care

syndromes/diseases commonly encountered with awareness of client's nutrition, culture, ethnicity and socioeconomic status.

8. Uses knowledge and awareness of the role of herbal and natural remedies while treating disease states.

3 (Continued on both sides of page)

(Rev. 03/2018)

Advanced Pharmacology Enabling Objectives have been developed through public input and are available upon request.

FACULTY QUALIFICATIONS All stated qualifications must be met by the faculty, include Directors and instructors. • Current, valid and clear license to practice in the appropriate discipline. • Demonstrates expertise in the theoretical and clinical aspects of pharmacology/pharmacotherapeutics. • Possesses at least two years of experience in the teaching of advanced pharmacology. • Includes a faculty member who has completed a doctoral level pharmacology/pharmacotherapeutics

degree. • Demonstrates evidence of advanced clinical practice within the past five years applying the principles of

advanced pharmacology.

ADVANCED PHARMACOLOGY ENABLING OBJECTIVES • Defines and verbalizes an understanding of the terminology of advanced pharmacology. (Vocabulary list

to be included) • Identifies sources of drugs and provides examples of drugs from each drug source. • Describes the "targets" of drugs. • Describes the pharmacokinetic process of absorption, distribution, metabolism, and excretion. • Identifies factorsthat alter the processes of absorption, distribution, metabolism, and excretion.

• "*li:!llyzes how tll~c)*~~t~~~~~ base envirolJ.!lti~~~ffe~ts the pharrn:~~~k!l'lgi~ proce$~¥~~~oifoti~~\ · o::d~~tribution, m~l;!ci'liiilf(:iJtltl.:e}(cretion ofdti\WI. ·.· ·' ·•>· · ',,,, : · '.·· · : .'.'• ' .·.· ' "'{, · ' · ·

• .· Describes variables that deter$lhe the correct dosages of:.irugs. .o·•·•:·. •·.·.· :. ·: · • De;fines half-life·'lwd explain~~l'!~impowiii:te of a drug's'i\1\if-life \ti:~ therape4lic drug regi$eh. •. Describes factoi{that influenc~adrug:~:~alf-life. ::( ••• ·,···· .' •••. • · · Ari~j)(zes the re!a£fonship betw~~J)dru~~!~nd their physiof~jcal atl(lpathophX~Mlogical resp&nses.

·.~,·· Un~*~tands the ~lJarmacokineli~ and ~1J;!irmacodynamic ~f{ects ofJ:lroad ((ilj~giiries of drug&, i.e., .. antill!iJtics, anti~f:Jiiythmics, ant!l'!yperti!~~Jves contracepti~if.S, etc. u§lict!ijs!)Wific treatmentf.~gimens. /. ~ .. . )J~~~ ~~ta obti!\.ll.~d during ~\~fiene~~istory and PhY¥\<:al Ex~riatioit(H&P) to idet)t,\iy appropriate

•. dfll!?i ~~<:>ice/s ~it~. herbs, vit'lffi.ihs, ~erals, and traqj; glemeri)~:,,regimenls, and recogg):?,:es the role of herbal and nat@iJ remediesirj}he tr~~pnent ofhealt\i ~~d dise~~~~tates. i):':

• Based \)pon thci:J?rjnciples ()()iharmaco~in~!ics and p~l'l'Jhacody~ics, identifies the in4~~~tions, rational~Jnd nl~9h~nisJ11Qf ~ction for dri:!~~.,%1);\19\'P[@ls drugs t~~~ to treat specific cond~ns.

• Undersi~J)(Is th<ilj)9te!J.tiaLinteractions betwe~~~Mi\~aild herbs, v~ins, minerals, and tralj~~;~lements. • Performs appropriate monitoring before, during, 'aiiil after specific drug regimens. • Monitors efficacy of drug/s evaluates the response and compliance of the client to the drugs/devices and

provides interventions for side effects, and manages adverse events that may occur. • Identifies drugs with narrow therapeutic range. • Identifies appropriate methods to write and transmit prescriptions. • Furnishes drugs pursuant to legal requirements, standardized procedures, ethical standards, and in

compliance with health and safety codes. • Identifies resources for drug information and uses the resources to maintain clinical competency for

furnishing. • Describes the essential components of client education re: medications including: name of medicationls

frequency/time of doses, correct dosage/s to take, how to take the medicationls i.e., with or without food, what to do if a dose of a medication is missed, side effects to expect, and adverse event/s to report to the prescriber.

• Identifies factors that influence medication compliance. • Provides comprehensive and appropriate client and family education re: drugs of choice and alternatives

and involves the client and family in the decision making process re: drug treatments. • Chooses most appropriate drug for a disease base upon client's symptomatology, health status and

lifestyle.

4 (Continued on both sides of page)

OUSU.IESS. COUSUMEA SEAvtCE5. AI() HOUSit.fj .AOEtl";f • ~)'·PtfT.M' EIJt AI lt () Go. EYY'.NII I Jk.

c::lc:a BOARD OF REGISTERED NURSING

DEPARTMENT OF CONSUMER AFFAIRS PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 I www.rn.ca.gov

(Rev 0312018)





EXECUTIVE OFFICER


P .0. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350

Authority which authorizes the maintenance of the information:

SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODE '•



FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE APPLICATION BEING REJECTED AS INCOMPLETE.

The principal purpose(s) for which the information is to be used:

TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBER/ITIN WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USC 405(c)(2)(C)) AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TO DISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER/ITIN, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON REQUEST IF AND WHEN YOU BECOME LICENSED.


POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING U.S. SOCIAL SECURITY NUMBER/ITIN TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE.


5

MANDATORY REPORTER

Under California law each person licensed by the Board of Registered Nursing is a "Mandated Reporter" for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Penal Code Section 11166 and will comply with those provisions.

California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the information concerning the incident.

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