Forms Page Shortcuts: Examination and Endorsement  /  Renewal and Reinstatement  /  Certificate of Authority /  Prescriptive Authority /Community Health Workers  /  Dialysis Technicians  /  Medication Aides  /  Complaint Forms  /  Post Disciplinary Monitoring  /  Alternative Program for Chemical Dependency

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General Information

   Adobe Acrobat File Name & Address Change Form (For All License & Certificate Holders)

Payments: Fees must be made payable to “Treasurer, State of Ohio”.  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.


Complaint Forms

To find out about the Ohio Board of Nursing complaint process, refer to the Discipline Section.

  Adobe Acrobat File   Complaint Form (for Email Submission)
  Adobe Acrobat File   (PDF) Version (for FAX or Postal Submission)

  Adobe Acrobat File   Supplemental Information Form for Employers (for Email Submission)
  Adobe Acrobat File   (PDF) Version  (for FAX or Postal Submission)

  Adobe Acrobat File   Nursing Education Program Dissatisfaction Form


Medication Aides    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: MA-C. This will help facilitate processing your request. If you held a Pilot Program Certificate and wish to obtain an Interim Certificate, please contact Angela White by phone at (614) 466-6966 or by e-mail at awhite@nursing.ohio.gov.

   Adobe Acrobat File   Medication Aide Application Packet
   Adobe Acrobat File   Name & Address Change Form (Top of Page)


Community Health Workers    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: COMMUNITY HEALTH WORKER UNIT. This will help facilitate processing your request.

   Adobe Acrobat File   Community Health Worker Application Packet
   Adobe Acrobat File   Name & Address Change Form (Top of Page)


Dialysis Technicians    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: DIALYSIS UNIT. This will help facilitate processing your request.

   Adobe Acrobat File   Dialysis Technician Application Packet
   Adobe Acrobat File   Name & Address Change Form (Top of Page)


Nurse License Renewal, Reactivation and Reinstatement    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: RENEWAL UNIT. This will help facilitate processing your request.

CHANGING YOUR ADDRESS:  Print this Name and Address Change Form located at the top of this page, fill it out completely, and either mail or fax it to the address/fax number found on the form. If there is no change in name, you may also e-mail all of the required information to renewal@nursing.ohio.gov. If your name has changed, the form must be mailed to the Board along with an official, certified copy of the legal document changing your name.

   Adobe Acrobat File   Affidavit of Lost Document
   Adobe Acrobat File   Reactivation and Reinstatement of a Nursing License
   Adobe Acrobat File   Name & Address Change Form (Top of Page)


Nurse Licensure by Examination and Endorsement    (Top of Page)

Important Information for Examination and Endorsement Applicants

The average processing time is 6-8 weeks from the date your application is received by the Board.

CHECKING THE STATUS OF YOUR APPLICATION: Check the status of your application on the Board’s web site at http://www.nursing.ohio.gov/Verification.htm. Click on ''verification" and you will be directed to the license and certificate verification site.  Refer to the instructions on the web page regarding recommended browsers.  If we have started processing your application, your name will appear as “pending” until your license is issued.

PROCESSING TIME: If it has been more than 8 weeks since you mailed your application, and your name does not appear on the license and certificate verification page, or you have not received your ATT (for examination applicants), contact the Licensure Unit at (614) 995-7675 or by e-mail at licensure@nursing.ohio.gov.  You will be asked to provide the date you mailed your application so that Board staff can assist you. If you want to confirm that the Board has received your application, you may want to send your application via delivery confirmation (i.e. Priority Mail, FedEx, UPS).  Do not contact the Board prior to this time, as this causes a further delay in processing applications.

PAYMENTS: Fees must be made payable to “Treasurer, State of Ohio”.  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.

ALL APPLICANTS: If you are mailing one of the forms below to the Board of Nursing, please send to ATTENTION: LICENSURE UNIT. This will facilitate the processing of your request. Please refer to the NEW background check instructions that are attached to the on-line examination and endorsement applications.

CRIMINAL RECORD CHECKS: Click Here For More Information

We are committed to issuing licenses as quickly as possible. Thank you for your patience.

Forms for Unlicensed Ohio Nurse Applicants (NCLEX required)

Examination Applicants: 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/nclex.

   Adobe Acrobat File   Examination Application Packet
   Adobe Acrobat File   Examination Application - Form A Transcript Authorization- Only out of state exam applicants are required to submit Form-A in addition to the standard Application for Examination.

    Adobe Acrobat File  Accommodations for the NCLEX Examination
    Adobe Acrobat File  The Eight Steps of the NCLEX (NCSBN Article)

Forms for Nurse Applicants (Already Licensed in Another State)

Endorsement Applicants: Complete Form B (enclosed) for verification of original licensure and/or current, valid licensure in good standing in another jurisdiction. If you hold a license in a NURSYS State, you must request a verification on-line at www.nursys.com. If you do not know if your state is part of the NURSYS system, you can view this information on this web site.

Adobe Acrobat File   Endorsement Application Packet for Out of State Applicants
   (Already Licensed in Another State and Never Having Been Licensed in Ohio)

We appreciate your patience.


Advanced Practice Nursing    (Top of Page)


If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: ADVANCED PRACTICE UNIT. This will help facilitate processing your request.

Fees must be made payable to “Treasurer, State of Ohio”.  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.

Certificate of Authority Forms

   Adobe Acrobat File   Certificate of Authority Application Packet

Prescriptive Authority Forms

Senate Bill 89 was enacted on December 28, 2009 and will be effective March 29, 2010. Revised applications for prescriptive authority are forthcoming.  Senate Bill 89 does not affect in-state applicants who hold a certificate of authority. Click Here to View the Complete Summary

   Adobe Acrobat File  CTP (In State Only) - Complete this application if you currently do not hold a certificate to prescribe in any jurisdiction.

Out of State Applicants (Please select the application below that applies to you.)

   Adobe Acrobat File  CTP (Out of State Only) - Complete this application if you currently hold a certificate to prescribe in another jurisdiction that includes the authority to prescribe controlled substances.

   Adobe Acrobat File  CTP (Out of State Only) - Complete this application if you currently hold a certificate to prescribe in another jurisdiction that does NOT include prescribing controlled substances.
  


Alternative Program for Chemical Dependency    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: ALTP. This will help facilitate processing your request.

   Adobe Acrobat File   Alternative Program for Chemical Dependency - FAQ

   Adobe Acrobat File  Form F - Current Employer List
   Adobe Acrobat File  Form G - Treating Healthcare Practitioner List
   Adobe Acrobat File  Form I - Personal Report
   Adobe Acrobat File  Form K - Probation Report
   Adobe Acrobat File     Form L - Work Performance Evaluation
   Adobe Acrobat File     Form P - Mental Health Waiver
   Adobe Acrobat File     Form T  -Provider List
   Adobe Acrobat File     Form V - Treatment Provider Waiver
   Adobe Acrobat File     Form W - Treatment Progress Evaluation
   Adobe Acrobat File     Form X - Healthcare Provider Evaluation
   Adobe Acrobat File     Form Z - Participant Treatment Plan


Compliance Program Post-Disciplinary Monitoring    (Top of Page)

If you are mailing one of the forms below to the Board of Nursing, please write on your envelope, along with the address, ATTENTION: MONITORING. This will help facilitate processing your request.

   Adobe Acrobat File   FirstLab Enrollment Packet and FAQs
      Adobe Acrobat File   Form 1 - Employer Report
      Adobe Acrobat File   Form 4 - Meeting Documentation
      Adobe Acrobat File   Form 5 - Medication Report
      Adobe Acrobat File   Form 6 - Medical Report
      Adobe Acrobat File   Form 7 - Prescription Medication Report
      Adobe Acrobat File   Form 9 - Mental Health Professional Report
      Adobe Acrobat File   Form 10 - Probation Report
      Adobe Acrobat File   Form 11 - Release of Information
      Adobe Acrobat File   Form 12 - Substance Abuse Treatment Program Report (Aftercare)
      Adobe Acrobat File   Form 13 - Substance Abuse Treatment Program Report
      Adobe Acrobat File   Form 14 - Treating Healthcare Practitioner List

      Adobe Acrobat FileContinuing Education Resource List

    Adobe Acrobat File Back to Top


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