Forms 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

PLEASE NOTE: Fees must be payable to “Treasurer, State of Ohio” and must accompany this application. Personal checks will not be accepted. Send a certified check, cashier’s check or money order. Business checks from government entities and education or training programs will be accepted. Payments must be drawn on a United States (U.S.) bank or 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   *NEW* Information Regarding Criminal Records Checks
   Adobe Acrobat File   Medication Aide Application
   Adobe Acrobat File   Form A
   Adobe Acrobat File   Supplemental Information Form


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   *NEW* Information Regarding Criminal Records Checks
   Adobe Acrobat File   Community Health Worker Application
   Adobe Acrobat File   Form A
   Adobe Acrobat File   Supplemental Information Form


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   *NEW* Information Regarding Criminal Records Checks
   Adobe Acrobat File   Dialysis Technician Application Instructions
   Adobe Acrobat File   Dialysis Technician Application
   Adobe Acrobat File   Form A
   Adobe Acrobat File   Form B
   Adobe Acrobat File   Form C
   Adobe Acrobat File   Form D
   Adobe Acrobat File   Registry Notice of Enrollee in a DT Program
   Adobe Acrobat File   Supplemental Information Form


Nurse License Renewal    (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 below, 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   Name/Address Change Form
   Adobe Acrobat File   Affidavit of Lost Document
   Adobe Acrobat File   Restoration of Nursing License - (Request for Reinstatement / Reactivation)
   Adobe Acrobat File   Restoration of Nursing License - (Supplemental Disclosure Form)


Nurse Licensure by Examination and Endorsement    (Top of Page)

Important Applicant Information - Please Read


PROCESSING TIME: The average processing time is 30-35 business days, from the date your application is received by the Board. This involves an initial review of the application, data entry into the Board’s database, and processing of your application fee. Once the initial review and processing of your application is complete, Board staff determine whether other application documents have been received (i.e. program completion letters, transcripts, license verifications, background check reports).

CHECKING YOUR STATUS: To determine if your application has been received and reviewed, please go to the Board web site at www.nursing.ohio.gov and click on “verification”. You will be redirected to the licensure verification web site used by the Board. If your application has been entered into the Board’s database, your name will appear in the list displayed. Once your name appears, it will display as “pending” until your license is issued.If it has been more than 35 business days since the Board received your application, and your name does not appear on the licensure verification page, or you have not received your ATT, please contact the Licensure Unit at (614) 995-7675 or by e-mail at licensure@nursing.ohio.gov. If it has been less than 35 business days, please do not contact the Board as there will not be any additional information that we can provide, and this causes a further delay in processing applications. Currently the Board is receiving several hundred calls and e-mails daily about the status of licenses, so your call or e-mail may not be returned immediately. We have seen an increase in licensure volume over the last several years and remain committed to issuing licenses as quickly as possible. We appreciate your patience.

PAYMENT: Fees must be payable to “Treasurer, State of Ohio” and must accompany this application. Personal checks will not be accepted. Send a certified check, cashier’s check or money order. Business checks from government entities and education or training programs will be accepted. Payments must be drawn on a United States (U.S.) bank or 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.

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.

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.

CRIMINAL RECORD CHECKS: Click Here For More Information

We appreciate your patience.

   Adobe Acrobat File   Endorsement Application for Out of State Applicants
   Adobe Acrobat File   Examination Application
   Adobe Acrobat File   Examination Application Instructions
   Adobe Acrobat File   Examination Applicant BCI&I Instructions
   Adobe Acrobat File   Examination Application Form-A Transcript Authorization


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 payable to “Treasurer, State of Ohio” and must accompany this application. Personal checks will not be accepted. Send a certified check, cashier’s check or money order. Business checks from government entities and education or training programs will be accepted. Payments must be drawn on a United States (U.S.) bank or payable in U.S. dollars. Please do not staple your payment to the application.

Prescriptive Authority Forms

   Adobe Acrobat File   Prescriptive Authority Application Cover Letter
   Adobe Acrobat File   Prescriptive Authority Instructions
   Adobe Acrobat File   Externship Instructions
   Adobe Acrobat File   Prescriptive Authority Application
   Adobe Acrobat File   Form E
   Adobe Acrobat File   Form G

Certificate of Authority Forms

   Adobe Acrobat File   Certificate of Authority Application Instructions
   Adobe Acrobat File   Certificate of Authority Application
   Adobe Acrobat File   Form A
   Adobe Acrobat File   Form B


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   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 File Back to Top


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