Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015

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1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Board of Nursing (802) Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015 Renewal Period Covering 04/01/2015 through 03/31/2017 Renewal Application Fee $ [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State You Must Complete The Information Below: For Office Use Only License #: Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal fee is nonrefundable. If the completed renewal application, along with all supporting documentation, is not received in the Office by the expiration date, you will be required to pay an additional penalty in addition to the renewal fee. Call the Office for a calculation of the penalty before submitting this renewal application. Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country If your 911 address has changed, indicate your new address in the box to the right. Street/Apt # Suite/Department/Floor City/State/Zip Country Phone: ( ) Cell Phone: ( ) Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female Social Security Number: / _/ _** (Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. 405(c)(2)(C). It will be used by the Departments of Taxes, and Child Support in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request);

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.

3 Section C: Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Since your license was last renewed (or since it was issued if within the last two years): Have you committed acts of abuse, neglect, or misappropriation of patient property? If, provide a detailed written explanation and attach all related documents. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Are you currently participating in a supervised program or professional assistance program which monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances? If please provide the contract/stipulation under which you are practicing.

4 Section D: APRN Nursing Education and Practice Requirements Vermont Board of Nursing Administrative Rule 8.19 Renewal Application Requirements To renew an APRN license the applicant must show: (a) graduation from an approved APRN program within the past 2 years; or (b) documentation of APRN practice for a minimum of: (1) 50 days (400 hours) in the previous 2 years; or (2) 120 days (960 hours) in the previous 5 years; and (c) current certification by a national APRN specialty certifying organization; and (d) current practice guidelines (if employed); and, (e) current collaborating provider agreement (if required). Program and Practice Experience Requirement (Check the box that applies to your license.) I have completed my original/initial APRN program or a Refresher program within the last two (2) years (4/1/2013 3/31/2015); therefore I do not have to meet the practice experience requirement. I have practiced as an APRN for paid compensation for 50 days (400 hours) within the last two (2) years or 120 days (960 hours) within the last 5 years. I have NOT met the program or practice experience requirement (You must contact the Board office at ) Do you have a DEA number? DEA Number Section E: Audit Information The Office of Professional Regulation reserves the right to verify information submitted by licensees for renewal through a random employment audit. You must retain all names and complete dates of employment for the five years prior to this renewal application. If you are selected for an audit, you will need to submit verification of employment from your employer(s) on the employer s letterhead. This must include the date range of your employment (mm/dd/yyyymm/dd/yyyy) and the total number of hours worked within the past 5 years. For Private Duty you will need the following: 1. An Official letter from the client/patient s attending Physician or Advanced Practice Registered Nurse (APRN) on their letterhead, stating that APRN care was required. The letter must clearly list the Physician s name, title, contact telephone number and have their signature. 2. A letter from your Employer or Client, verifying your role and duties as a Private Duty APRN. They must verify the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact telephone number, address, mailing address and have their signature. For Volunteer Duty you will need the following: An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer APRN, and a letter listing the number of days, hours and dates worked. The letter must clearly list the name of the Physician, Director of Nursing or Director of Human Resources, their telephone number, address, mailing address and have their signature.

5 Section F: Late Renewals If you are renewing more than 30 days late, you must submit: A completed renewal application Verification of employment from your employer(s) on the employer s letterhead. The letter must include the date range of your employment (mm/dd/yyyy mm/dd/yyyy) and the total number of hours worked within the past 5 years. If you met the practice requirement via Private Duty or Volunteer work and are renewing more than 30 days late, you must submit a completed renewal application, and the requirements noted in Section E. If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section G: Required Attachments Submit a copy of your current national advanced nursing practice specialty certification. If employed: Practice guidelines must be original, signed and dated by you and your collaborating provider (if you are in the transition to practice period.) If you do not require a Collaborative provider, practice guidelines must still be original, signed and dated by you. Please be sure you have submitted your APRN Attestation of Completion to Transition to Practice form. Practice guidelines are required prior to employment. Copies and noncurrent practice guidelines will not be accepted. Section H: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant **(REQUIRED)** Signature Date (MM/DD/YYYY) **(REQUIRED)** Print Name: License # _

6 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2015 Renewal License #: Name: 1. Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise?

7 Vermont License Number retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) Birthdate (mmddyyyy) First Name Middle Initial 1 Last Name Gender: Male Female 1. Are you Hispanic or Latino/a? (check all that apply) Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Choose not to respond 3. What type of nursing degree or credential qualified you for your first U.S. RN license? Vocational/Practical certificate nursing Diploma nursing Associate Degree (nursing) Bachelor s Degree (nursing) Master's Degree (nursing) Doctoral Degree nursing (PhD) Doctoral degree nursing practice (DNP) Other 4. In what year did you complete that degree? 5. Enter the twoletter code for the state where you completed that degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 2. Race? (check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Other Choose not to respond 6. What is your highest earned degree to date? Vocational/Practical certificate nursing Diploma nursing Associate Degree (nursing) Bachelor s Degree (nursing) Bachelor s degree other field Master's Degree (nursing) Master s degree other field Doctoral Degree nursing (PhD) Doctoral degree nursing practice (DNP) Doctoral degree other field Other 7. Are you currently enrolled in a nursing education degree program? not enrolled Master's Degree program Doctoral Degree program (PhD) Doctoral degree nursing practice (DNP) Other 8. For how many years have you worked as an RN (anywhere)? 9. For how many years have you worked as an APRN (anywhere)? Please continue on next page. Thank you

8 retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 2 Vermont License Number (Please reenter your license number for scanning purposes) 10. In what state(s) do you hold an active APRN license? State (postal) abbreviation(s): 11. In what state(s) are you currently actively practicing as an APRN? State (postal) abbreviation(s): 12. Which APRN license(s) do you 14. In what areas do you hold credentials currently hold? (check all that apply) as an APRN? (check all that apply) Nurse Practitioner (NP) Adult Clinical Nurse Specialist (CNS) Family Certified Nurse Midwife (CNM) Pediatrics Certified Registered Nurse Anesthetist (CRNA) Gerontology Midwifery (full scope) OB/Gyn (women s health) Medical / Surgical 13. Which nonnursing license(s) do you hold, if any? Psych / Mental Health Alcohol and Drug Abuse Counselor Anesthesiology Physical Therapy Acute / Emergency Care School 15. What is your employment status? (check all that apply) Actively working in a nursing position part or full time Working per diem as a nurse Working in nursing but only as a volunteer Working in a field other than nursing t currently working seeking work as a nurse t currently working not seeking work as a nurse Retired 16. Do you currently work in Vermont as an APRN? 17. If no, do you plan to start (or resume) working in Vermont as an APRN within the next 12 months? * 18. For how many years have you worked in Vermont as an APRN? IF you are NOT currently working IN VERMONT as an APRN, PLEASE STOP HERE AND RETURN SURVEY 19. Do you have Hospital Privileges in Vermont? Please continue on next page. Thank you

9 retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 3 Vermont License Number (Please reenter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you currently work IN VERMONT as an APRN If you provide care at two locations in the same town, please enter each as a separate site. SITE ONE (principal site) TOWN for the Vermont location where you work, not a mailing address: Practice Name and Street Address (not a mailing address): ZIP code for the Vermont location where you work, not a mailing address: Which best describes the setting of this practice location? (choose one) Physician/APRN Practice Independent APRN Practice solo Independent APRN Practice group Hospital outpatient Hospital inpatient Nursing Home / Extended Care Home Health Correctional Facility Public Health Community Health Center Mental Health Center School or College Health Service Occupational Health Academic Setting Other setting: Please enter the number of weeks in a year during which you work at this site as an APRN: (48 weeks is considered "year round") WEEKS Per Year Please identify the title that most closely corresponds to your primary nursing practice position at this site: (choose one) Nurse Executive Nurse Manager Nurse Faculty Advanced Practice Nurse (patient care) Staff Nurse (patient care) Consultant/Nurse Researcher Other Health Related Other t Health Related Do you work here on a per diem basis? Do you work here as a traveler? Which patient types are commonly served by you at this practice site? (check all that apply) Neonatal Pediatric Adult Geriatric All Ages n.a. Do you accept new patients here? New Medicaid patients? Please continue on next page. Thank you

10 retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 4 Vermont License Number (Please reenter your license number for scanning purposes) Please identify the employment specialty that most closely corresponds to your primary practice at this site: (select ONE) Acute care / Critical Care Adult Health / Family Health Anesthesia Community Dermatology Disability Evaluation Endocrinology Geriatric / Gerontology Home Health Internal Medicine Maternal Child Health Medical Surgical Occupational Health Oncology Orthopedics Palliative Care Pediatrics / Neonatal Public Health Rehabilitation School Health Trauma Women s Health Indicate your average number of patient care hours here per working week in your primary specialty mentioned above: (Enter "0" if you do not provide patient care) patient care HOURS per week Please identify the employment specialty that most closely corresponds to your secondary practice at this site, if any: Acute care / Critical Care Adult Health / Family Health Anesthesia Community Dermatology Disability Evaluation Endocrinology Geriatric / Gerontology Home Health Internal Medicine Maternal Child Health Medical Surgical Occupational Health Oncology Orthopedics Palliative Care Pediatrics / Neonatal Public Health Rehabilitation School Health Trauma Women s Health Indicate your average number of patient care hours here per working week in your secondary specialty mentioned above: (Enter "0" if you do not provide patient care) patient care HOURS per week Indicate your Hours per working week in administration at this site: Indicate your Hours per working week in supervision at this site: Indicate your Hours per working week in other activities at this site: Please specify: HOURS per week HOURS per week HOURS per week Please return all sheets (6 pages) even if some are blank. Thank you

11 retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 5 Vermont License Number (Please reenter your license number for scanning purposes) * If you have a second practice site, continue. If you only have one practice site, stop here, but return all 6 pages. SITE TWO (if any) TOWN for the Vermont location where you work, not a mailing address: Practice Name and Street Address (not a mailing address): ZIP code for the Vermont location where you work, not a mailing address: Which best describes the setting of this practice location? (choose one) Physician/APRN Practice Independent APRN Practice solo Independent APRN Practice group Hospital outpatient Hospital inpatient Nursing Home / Extended Care Home Health Correctional Facility Please identify the title that most closely corresponds to your primary nursing practice position at this site: (choose one) Nurse Executive Nurse Manager Nurse Faculty Advanced Practice Nurse (patient care) Staff Nurse (patient care) Consultant/Nurse Researcher Other Health Related Other t Health Related Public Health Community Health Center Mental Health Center School or College Health Service Do you work here on a per diem basis? Do you work here as a traveler? Occupational Health Academic Setting Other setting: Please enter the number of weeks in a year during which you work at this site as an APRN: (48 weeks is considered "year round") WEEKS Per Year Which patient types are commonly served by you at this practice site? (check all that apply) Neonatal Pediatric Adult Geriatric All Ages n.a. Do you accept new patients here? New Medicaid patients?

12 Please continue on next page. Thank you retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 6

13 retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you. You may respond online instead, at: survey.healthvermont.gov/s3/apn15 7 Vermont License Number (Please reenter your license number for scanning purposes) Please identify the employment specialty that most closely corresponds to your primary practice at this site: (select ONE) Acute care / Critical Care Adult Health / Family Health Anesthesia Community Dermatology Disability Evaluation Endocrinology Geriatric / Gerontology Home Health Internal Medicine Maternal Child Health Medical Surgical Occupational Health Oncology Orthopedics Palliative Care Pediatrics / Neonatal Public Health Rehabilitation School Health Trauma Women s Health Indicate your average number of patient care hours here per working week in your primary specialty mentioned above: (Enter "0" if you do not provide patient care) patient care HOURS per week Please identify the employment specialty that most closely corresponds to your secondary practice at this site, if any: Acute care / Critical Care Adult Health / Family Health Anesthesia Community Dermatology Disability Evaluation Endocrinology Geriatric / Gerontology Home Health Internal Medicine Maternal Child Health Medical Surgical Occupational Health Oncology Orthopedics Palliative Care Pediatrics / Neonatal Public Health Rehabilitation School Health Trauma Women s Health Indicate your average number of patient care hours here per working week in your secondary specialty: patient care HOURS per week Indicate your Hours per week at this site spent on: Administration Supervision Other activities: If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you

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