LICENSURE BY EXAMINATION APPLICATION INSTRUCTIONS

LICENSURE BY EXAMINATION APPLICATION INSTRUCTIONS NOTE: It is the applicant s responsibility to have all required documentation sent to the Ohio Board of Nursing (Board). Questions regarding your application can be directed to the Board at (614) 995-7675 three weeks after the date you sent the application. Please allow up to 6-8 weeks processing time. 1. NCLEX Examination (NCLEX) Registration with Pearson VUE (testing service) and the Board CANDIDATES MUST REGISTER WITH BOTH THE BOARD AND PEARSON VUE YOU WILL NOT RECEIVE YOUR AUTHORIZATION TO TEST NUMBER UNTIL YOU HAVE REGISTERED WITH AND MET ALL REQUIREMENTS OF THE BOARD AND PEARSON VUE NCLEX Registration Candidates can visit www.pearsonvue.com/nclex to register for the NCLEX ; print a registration confirmation; download the NCLEX Candidate Bulletin to obtain detailed instructions, fee information, and Education Program Codes; and pay the NCLEX fee. A candidate may also register for the NCLEX by contacting Pearson VUE at 1-866-496-2539. Board Application The Board must receive a completed Licensure by Examination Application to determine eligibility to take the NCLEX. Pearson VUE will send the Authorization to Test (ATT) document to the applicant after the applicant is made eligible to test by the Board. The applicant must have an ATT number in order to schedule an appointment with Pearson VUE to take the NCLEX. Please note that the Board does not create or issue ATT numbers. 2. Complete the entire application in ink or typed print. PLEASE PRINT LEGIBLY 3. Photograph Provide a recent, (2 x 2 ), unmounted, full face (head shot), passport type photograph, less than 12 months old. Polaroid photographs (with the black backing) or photocopies will not be accepted. ID badges/cards, photographs cut from or copies of other identification cards (such as your driver s license or employee badge) will not be accepted. Print your name and social security number on the back of the photograph and attach it to the designated area on the application with tape. Please do not fold the application where the photograph is attached. Please note that if the submitted photograph does not meet the requirements or the quality is too poor to archive, the entire application may be returned to you. 4. Non-Refundable Application Fee A $75 non-refundable fee payable to Treasurer, State of Ohio must accompany this application. Personal checks or cash will not be accepted. Send a certified check, cashier s check or money order. Business checks from government entities, corporations, and education or training programs will be accepted. Payments must be drawn on a United States (U.S.) bank and payable in U.S. dollars. Please do not staple your payment to the application. 5. Required Documentation for Education Please follow the instructions for the category below that best describes your education: Graduates of Approved Ohio Nursing Education Programs The director of the program must submit directly to the Board, a program completion letter certifying: the applicant completed all program curriculum requirements and all other requirements of the controlling agency; the date the applicant entered the program; the date of program completion (not graduation); and the type of certificate/diploma awarded. LPN Ohio Graduates-All licensed practical nurse applicants who have graduated from an approved Ohio nursing education program must have an Intravenous (IV) Therapy designation on their program completion letter in order to administer IV Therapy in Ohio. Graduates of Non-Ohio Nursing Education Programs The nursing education program must send a signed and sealed transcript directly to the Board. The diploma, certificate or degree, and the date of completion must be indicated on the transcript. Form A may be used to obtain this transcript. Copies of transcripts sent by applicants will not be accepted. If your nursing program is closed, it is your responsibility to locate the custodian of your records. If your transcript does not clearly indicate the degree awarded and date of completion, the custodian of the transcript is required to attach a cover letter on official letterhead listing the information. 1

LPN Non-Ohio Graduates-All licensed practical nurses who are graduates of non-ohio nursing education programs must provide evidence of successful completion of a course in medication administration in order to be authorized to administer medications or evidence of successful completion of an IV course in order to be authorized to perform limited IV Therapy. Evidence of a medication administration/pharmacology or IV course must be listed on the transcript sent directly from the education program. For IV Therapy, you must also submit a syllabus and/or course curriculum demonstrating successful completion of a course in the administration of IV Therapy. If it is determined that your coursework meets Ohio criteria for IV Therapy, you will be required to take a one hour module related to Ohio law and rules. Foreign Educated Applicants Contact The Commission on Graduates of Foreign Nursing Schools (CGFNS) at (215) 349-8767 and request the Credentials Evaluation Service Application Packet. Enter Ohio Board of Nursing as the recipient of the report and select Full Education Courseby-Course as the report type on the application. The report must be sent directly from CGFNS to the Board. 6. English Proficiency for Foreign Educated Applicants Proof of English proficiency is required and may be met by satisfactorily completing the Test of English as a Foreign Language (TOEFL ibt). Refer to the application for a list of acceptable tests and passing scores. Contact Educational Testing Services (ETS) at (609) 771-7100. Test scores must be sent directly to the Board from the testing agency. A foreign educated nurse graduate whose native language is English and who graduated from a college, university, or professional training school located in Australia, Canada (except Quebec), Ireland, New Zealand, or the United Kingdom is not required to comply with this requirement. 7. Accommodations For candidates with disabilities defined by the American Disabilities Act (ADA), accommodations are authorized only by the Board and the National Council of State Boards of Nursing. The Board recommends that the applicant notify the Board, in writing, six months prior to program completion. The applicant is required to submit the following documentation: (1) Letter from the applicant specifying requested accommodations; (2) Letter from the Director/Designee of the nursing education program specifying accommodations granted by the nursing program; and (3) Diagnostic report from a qualified professional practitioner. 8. Criminal Record Checks A BCI (civilian) and FBI (federal) criminal records check is required for all applicants who entered a pre-licensure nursing education program on or after June 1, 2003. Refer to the on-line instructions regarding criminal records checks unless you have already had them done and they have been submitted to the Board. 9. Affidavit Sign and complete the appropriate affidavit on the application. The affidavit must be signed and notarized after completion of the entire application. 10. Processing Information It is your responsibility to insure that all required materials such as program completion letters, transcripts and criminal records check reports are received by the Board directly from the appropriate agency. Please DO NOT send documents that are not requested in this application such as your birth certificate or a copy of your diploma. Notify the board in writing within 30 days of any address change or name change. A name change requires a certified copy of documentation such as a marriage certificate, court record or a divorce decree. A photocopy or notarized copy is not acceptable. Please return your completed, signed and notarized application, photograph and a $75 non-refundable fee to: Ohio Board of Nursing Attention: Licensure Unit 17 South High Street, Suite 400 Columbus, Ohio 43215-7410 If any part of this application is incomplete, the application may be returned. To determine if your application has been received and reviewed, please go to the Board website at www.nursing.ohio.gov, click on verification and enter your name. Once your name appears, it will display as pending until your license is issued. If an Application for Licensure by Examination submitted to the Board remains incomplete for one year, the application shall be considered void and the fee submitted with the application shall be forfeited. NOTE: YOU WILL NOT BE MADE ELIGIBLE TO TEST UNTIL ALL APPLICATION REQUIREMENTS HAVE BEEN MET WITH BOTH THE BOARD AND PEARSON VUE. 2

Application for Licensure by EXAMINATION to Practice Nursing in Ohio A) GENERAL INFORMATION (Complete the entire application in ink or typed print. PLEASE PRINT LEGIBLY) I am applying for licensure by examination as a:! Licensed Practical Nurse (LPN)! Registered Nurse (RN) Full Legal Name Last First Middle Maiden Social Security Number* Address City State Zip County of Residence Telephone Number E-Mail Address Date of Birth Place of Birth City State Country Gender! Male! Female Race (optional)! African American/Black! Asian! Hispanic/Spanish Origin! Other! American Indian! Caucasian/White! Indian (country) B) BASIC NURSING EDUCATION PROGRAM INFORMATION Education Program Code (To obtain your Education Program Code, you may request a copy of the NCLEX Bulletin by contacting Pearson Vue at 1-866-496-2539 or on-line at www.vue.com). Name of School City State Country Date of Entrance (month/ day/ year) / / Type of Program Date of Completion/Anticipation (month/ day/ year) / /! Associate Degree! Certificate! Diploma! Baccalaureate! Other LPN Non-Ohio Graduates: I successfully completed a course in IV Therapy (See Instructions #5)!Yes!No C) NURSING PRACTICE Have you ever been licensed to practice nursing in Ohio? Yes! No! If yes, please indicate RN or LPN and license number Have you ever been licensed to practice nursing in any state other than Ohio? Yes! No! If yes, please indicate LPN or RN D) CITIZENSHIP **! United States! Alien lawfully admitted for permanent residency in the United States (attach copy of front and back of alien registration card)! Other non-immigrant status (attach copy of documentation)! I am a foreign national not living in the United States *Your social security number is required by state law and federal law for purposes of child support enforcement (ORC 3123.50, 42 U.S.C. Section 666), reporting to the Federal Healthcare Integrity and Protection Data Bank (42 U.S.C. Sections 1320a-7e(b), 5 U.S.C. Section 552a, and 45 C.F.R. pt. 61). It may also be used for reporting to the National Practitioner Data Bank (42 U.S.C. Section 11101 and 45 C.F.R. pt. 60), reporting to law enforcement authorities for investigative/law enforcement purposes in compliance with ORC 4723.28, reporting to the National Council of State Boards of Nursing for state board investigative purposes, and/or as otherwise required by state and federal law. ** If you are living in the United States, Federal Law [8 USCS 1621] [PRWORA], limits the issuance of professional licenses to U. S. citizens or aliens lawfully admitted to the U.S.

E) ENGLISH PROFICIENCY FOR FOREIGN EDUCATED APPLICANTS ONLY ALL candidates must achieve a minimum passing score of 83 or higher on the Test of English as a Foreign Language Internet-based Testing (TOEFL ibt). Test scores must be sent directly to the Board from the testing agency. F) PHOTOGRAPH Please read instructions carefully. Provide a recent, (2 x 2 ), unmounted, full face (head shot), passport type photograph, less than 12 months old. ID badges/cards, photographs cut from or copies of other identification cards (such as your Driver s license or employee badges) WILL NOT BE ACCEPTED. No Polaroid photographs (with the black backing) or photocopies. Do not fold application where photograph is attached. Please Note: If the photograph submitted does not meet the requirements or the quality is too poor to archive, the entire application may be returned to you. Attach (2 x 2 ) photograph with tape here. Print name and Social Security Number on the back of the photograph.

G. COMPLIANCE Please circle Yes or No to each question. Your application is not complete until the Board has received ALL required documents. CAUTION: False, and/or misleading information provided by an applicant may result in the denial/permanent denial of a license/certificate. 1. Have you EVER been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of Yes No insanity to, entered an Alford plea, received treatment or intervention in lieu of conviction, or received diversion for any of the following crimes (this includes crimes that have been expunged IF there is a direct and substantial relationship to nursing practice)? Please answer BOTH questions a and b. a. A felony in Ohio, another state, commonwealth, territory, province, or country? Yes No b. A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? Yes No (This does not include traffic violations unless they are DUI/OVI) 2. Have you ever been found to be mentally ill or mentally incompetent by a probate court? Yes No 1. If 3you answered Yes to a box above, you are required to provide the Board with a written explanation of the events including. the date, county and state in which the events occurred (attach a separate sheet to this application), and a certified copy of the indictment(s) or criminal complaint(s), plea(s), journal entry(s) from the appropriate court. A copy of the court docket or case summary does not meet this requirement. 3. Has any board, bureau, department, agency or other public body, including those in Ohio, other than this Board, in any Yes No way limited, restricted, suspended, or revoked any professional license or certificate granted to you; placed you on probation; imposed a fine, censure or reprimand against you? Have you ever voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate or registration? 4. Have you ever, for any reason, been denied an application, issuance or renewal for licensure/certification, or the Yes No privilege of taking an examination, in any state (including Ohio), commonwealth, territory, province, or country? 5. Have you ever entered into an agreement of any kind, whether oral or written, with respect to a professional license or Yes No certification in lieu of or in order to avoid formal disciplinary action with any board, bureau, department, agency, or other public body, including those in Ohio, other than this Board? 6. Have you been notified of any current investigation of you, or have you ever been notified of any formal charges, Yes No allegations, or complaints filed against you by any board, bureau, department, agency, or other public body, including those in Ohio, other than this Board, with respect to a professional license or certification? If you answered Yes to questions 3-6, you are required to provide the Board with a written explanation and certified copies of any documents. 7. Have you ever been diagnosed as having, or have you been treated for, pedophilia, exhibitionism, or voyeurism? Yes No 8. Within the last five years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, Yes No paranoia, or any other psychotic disorder? 9. Have you, since attaining the age of eighteen or within the last five years, whichever period is shorter, been admitted to Yes No a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? If you answered Yes to question 7, 8, or 9 you are required to provide a written explanation, including date(s) of diagnosis or treatment, and a description of your present condition. Include the name, current mailing address, and telephone number of each person who treated you, as well as each facility where you received treatment, and the reason for treatment. Have each treating physician submit a letter detailing the dates of treatment, diagnosis and prognosis. 10. Are you currently engaged in the illegal use of chemical substances or controlled substances? For this question Currently does not mean on the day of, or even weeks or months preceding the completion of this application. Rather, it means recently enough so that the use of drugs may have an ongoing impact on one s functioning as a certificate holder or licensee, or within the past two years. Illegal use of chemical substances or controlled substance means the use of chemical substances or controlled substances obtained illegally (e.g. heroin, cocaine, or methamphetamine) as well as the use of controlled substances, which are not obtained pursuant to a valid prescription, or not taken in accordance with the direction of a licensed healthcare practitioner. a. If you answered Yes to question 10, are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not illegally using chemical substances or controlled substances? If you answered Yes, you are required to provide a written explanation. If you are participating in a monitoring program, you are required to cause the respective program to provide information detailing your participation in and compliance with the program. 11. Have you been notified of any proceeding to determine whether you may be subject to listing on the Sexual Civil Child Abuse Registry established by the Ohio attorney general pursuant to section 3797.08 of the Revised Code, and/or are you listed on that registry? IF ANY QUESTION IS LEFT UNANSWERED. APPLICATION WILL BE RETURNED. Yes Yes Yes No No No

Last Name First Name M.I. (Print clearly, your full legal name as it appears on the first page of the application) Sign, complete, and have notarized ONLY ONE affidavit that applies to you. REGISTERED NURSE (RN) AFFIDAVIT LICENSED PRACTICAL NURSE (LPN) AFFIDAVIT I, Full Legal Name - print I, Full Legal Name - print am the person in this application for Licensure and the statements made herein are true. am the person in this application for Licensure and the statements made herein are true. I hereby give consent to be fingerprinted anytime after I take the licensure examination if requested by the Board to investigate a possible security violation of the examination. The law regulating the practice of nursing states that the Ohio Board of Nursing may revoke, permanently revoke a license, and deny or permanently deny a licensure application to a person found by the Board to have committed fraud in passing the examination or to have committed fraud, misrepresentation, or deception in applying for or securing any license issued by the Board. No person may engage in the practice of nursing as a Registered Nurse in Ohio for a fee, salary, or other consideration, or as a volunteer, unless holding a current, valid Ohio license as a Registered Nurse. I hereby request that in order to process my application, act upon renewal requests, and respond to public requests to confirm my license/certificate status, my personal information be accessed in accordance with OAC 4723-1-11(D)(2)(d)(ii). I have read and understand this Affidavit and consent for fingerprinting. Legal Signature of Applicant: Notary: Signed and sworn before me this day I understand that if I have not completed a medication administration course with both theoretical and clinical components, I will not be authorized to administer medications, and my license will include a medication restriction. I further understand that I must obtain a Board approved IV therapy card in order to perform any IV therapy procedures. I hereby give consent to be fingerprinted anytime after I take the licensure examination if requested by the Board to investigate a possible security violation of the examination. The law regulating the practice of nursing states that the Ohio Board of Nursing may revoke, permanently revoke a license, and deny or permanently deny a licensure application to a person found by the Board to have committed fraud in passing the examination or to have committed fraud, misrepresentation, or deception in applying for or securing any license issued by the Board. No person may engage in the practice of nursing as a Licensed Practical Nurse in Ohio for a fee, salary, or other consideration, or as a volunteer, unless holding a current, valid Ohio license as a Licensed Practical Nurse. I hereby request that in order to process my application, act upon renewal requests, and respond to public requests to confirm my license/certificate status, my personal information be accessed in accordance with OAC 4723-1-11(D)(2)(d)(ii). I have read and understand this Affidavit and consent for fingerprinting. of, 20. Legal Signature of Applicant: Signature of Notary Public: Expiration Date of Commission: Notary: Signed and sworn before me this day of, 20. Signature of Notary Public: (NOTARY SEAL) Expiration Date of Commission: (NOTARY SEAL) For Board Use ONLY Date Issued-License Number LPN! LPN-MEDS! LPN M-IV! RN! Failed: IN Photo! BCI! FBI! Program Letter! Transcript! IV Therapy! Med Admin.! CGFNS! English Prof.! Citizenship! SAVE! MODS Request! Applicant Letter! Director Letter! Dr. Letter/Diagnosis! Other:

CRIMINAL RECORDS CHECKS REQUIRED FOR LICENSURE OR CERTIFICATION If you have already completed your background checks, please disregard this letter. If you have not completed your background check, please read on. The Ohio Revised Code requires those applying for a license or certificate issued by the Ohio Board of Nursing (Board) to submit fingerprints for an FBI (federal) and BCI (civilian) criminal records check completed by the Bureau of Criminal Identification and Investigation (BCI&I). The Board cannot, by law, complete the processing of your application until the Board receives BOTH background check reports. BCI&I will ONLY accept electronic fingerprints for FBI and BCI background checks, except for the reasons listed below. Electronic fingerprints must be completed by a Webcheck location in Ohio that will submit the applicant s fingerprints electronically to BCI&I. The applicant must request that BOTH reports be sent to the Board DIRECTLY from BCI&I, or they will not be accepted by the Board. A complete list of Webcheck locations is available online at the following website address: www.ohioattorneygeneral.gov/services/business/webcheck/webcheck-community-listing When locating an electronic fingerprinting site on this web page, please note that only the locations designated with the notation of BCI & FBI perform both the BCI and FBI records check. The Board does not endorse or recommend any specific Webcheck fingerprinting company. Fingerprint cards will only be accepted by BCI&I (with an Exemption Form) for one of the following reasons: Applicant s home address is 75 miles or more from the nearest Webcheck location; Amputations or digits missing (Webcheck 4.0 only); Out-of-state applicant; Poor quality prints (Not able to capture at Webcheck location, provide name of location where the background check was attempted on the waiver form); BCI/FBI rejects from original electronic submission. Note: The original reject letter must accompany the fingerprint card (s); and Public Housing Organization background checks. Waivers of the electronic submission requirement will be evaluated on a submission by submission basis. No blanket or agency-wide waivers will be granted. Exemption requests that are denied will be returned to the submitting agency. Any card that is submitted without a waiver form will also be returned. Please note: If you have questions about any of the qualifying exemptions, please contact BCI&I at (740) 845-2375. If you meet any of these exemptions, please submit your name and complete address to the Board in writing (Attention: CRC) at the above address, by fax at (614) 466-0388, or by email at crc@nursing.ohio.gov to request fingerprint cards and instructions for completing the cards.