Ohio Board of Nursing - Forms and Applications

Page Shortcuts: Name and Address Changes / Examination and Endorsement  /  Renewal and Reinstatement  /  Advanced Practice Registered Nurse (APRN) /Community Health Workers  /  Dialysis Technicians  /  Medication Aides  /  Complaint Forms  /  Post Disciplinary Monitoring  /  Alternative Program for Chemical Dependency /Education Forms / Volunteer Certificate Forms

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General Information

Online payments:

Fees must be paid online at the time of application or renewal, and are non-refundable. Use Master Card, VISA or Discover credit or debit cards. If you do not have this type of personal credit or debit card, you can obtain these pre-paid cards at local stores to use for renewal. If the fee is not paid when you submit your application, the application will be incomplete and will not be processed.

*Notarized signatures are no longer required for licensure and certification applications.


Name & Address Changes

Managing Your License and Certificate Online

Beginning July 1, 2016 name and address changes must be performed online by accessing the new eLicense 3.0 licensure system. Name changes must also be submitted as a Service Request within eLicense 3.0 and will require submission of additional documentation.

  Adobe Acrobat FileName Change Form (For All License & Certificate Holders) - Sample Only Not for Submission

  Adobe Acrobat FileRequest for Replacement Wall Certificate Form - Sample Only Not for Submission



Complaint Forms

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

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

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

  Adobe Acrobat FileNursing Education Program Dissatisfaction Form



Medication Aides Forms

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

If you are mailing one of the secondary 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.

CRIMINAL RECORD CHECKS: Click Here For More Information

  Adobe Acrobat FileMedication Aide Application - Sample Only Not for Submission
  Adobe Acrobat FileMedication Aide Application - Form A
  Adobe Acrobat FileMedication Aide Renewal Application - Sample Only Not for Submission
  Adobe Acrobat FileMedication Aide Reactivation and Reinstatement Application - Sample Only Not for Submission

Adobe Acrobat File Apply Online
 
Program Approval Forms

Adobe Acrobat FileMedication Aide Training Program Application

Adobe Acrobat FileMedication Aide Training Program Re-Approval Application



Community Health Workers Forms

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

If you are mailing one of the secondary 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.

CRIMINAL RECORD CHECKS: Click Here For More Information

  Adobe Acrobat File Community Health Worker Application - Sample Only Not for Submission
  Adobe Acrobat File Community Health Worker Application - Form A
  Adobe Acrobat File Community Health Worker Renewal Application - Sample Only Not for Submission
  Adobe Acrobat File Community Health Worker (CHW) Reactivation and Reinstatement Application - Sample Only Not for Submission

Adobe Acrobat File Apply Online

Program Approval Forms

   Adobe Acrobat FileCommunity Health Worker Program Approval Process
   Adobe Acrobat FileCommunity Health Worker Program Approval Application (MS Word Format)
   Adobe Acrobat FileCommunity Health Worker Program Re-Approval Application (MS Word Format)



Dialysis Technicians Forms

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

If you are mailing one of the secondary 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.

CRIMINAL RECORD CHECKS: Click Here For More Information

  Adobe Acrobat File Dialysis Technician Application - Sample Only Not for Submission
  Adobe Acrobat File Dialysis Technician Application Supplimental Forms A, B, C & D
  Adobe Acrobat File Dialysis Technician, Renewal Application - Sample Only Not for Submission
  
Adobe Acrobat File Dialysis Technician, Reactivation and Reinstatement Application - Sample Only Not for Submission
  Adobe Acrobat File Dialysis Technician Testing Organization Initial & Renewal Application - Sample Only Not for Submission

Adobe Acrobat File Apply Online

Program Approval Forms

   Adobe Acrobat FileDialysis Technician Training Program - Initial Approval Packet
   Adobe Acrobat FileDialysis Technician Training Program - Re-Approval Packet 



Nurse License Renewal, Reactivation and Reinstatement Process Information and Forms

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

If you are mailing one of the secondary 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.

CRIMINAL RECORD CHECKS: Click Here For More Information

   Adobe Acrobat FileAffidavit of Lost Document - Sample Only Not for Submission
  
  Adobe Acrobat File RN Renewal Application - Sample Only Not for Submission
  Adobe Acrobat File RN Reactivation and Reinstatement Application - Sample Only Not for Submission

  Adobe Acrobat File LPN Renewal Application - Sample Only Not for Submission
  Adobe Acrobat File LPN Reactivation and Reinstatement Application - Sample Only Not for Submission

Adobe Acrobat File Apply Online



Nurse Licensure by Examination and Endorsement Process Information and Forms

Important Information for Examination and Endorsement Applicants

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

If you are mailing one of the secondary 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 background check instructions that are attached to the examination and endorsement applications.

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.  Once we have started processing your application, your name will appear as “pending” until your license is issued.

ONLINE PAYMENTS: Fees must be paid online at the time of renewal. Use Master Card, VISA or Discover credit or debit cards. If you do not have this type of personal credit or debit card, you can obtain these pre-paid cards at local stores to use for renewal. If the fee is not paid when you submit your application, the application will be incomplete and will not be processed.

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.

All licensure and certification applications must be completed online. Please go to the online eLicense website at "eLicense.Ohio.gov" to access the online applications. The "sample" applications on this web page are for reference only and are provided for informational purposes.

CRIMINAL RECORD CHECKS: Click Here For More Information

   Adobe Acrobat FileNursing License by Examination Application- SAMPLE ONLY - NOT FOR SUBMISSION - Includes information for foreign educated nurses.

   Adobe Acrobat FileExamination Application - Form B Transcript Authorization- SAMPLE ONLY - NOT FOR SUBMISSION - Only out of state exam applicants are required to submit Form-B in addition to the standard Application for Examination.

Adobe Acrobat FileFind Your Correct Nursing School Code Here

Adobe Acrobat File LPN IV-Therapy Application - Sample Only Not for Submission

Adobe Acrobat File Apply Online

   Adobe Acrobat FileOhio Nursing Education Programs - School Code List


Forms for Nurse Applicants (Already Licensed in Another State)

Endorsement Applicants: Complete Form A, for verification of original licensure and/or a current, valid, and unrestricted license 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.

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

CRIMINAL RECORD CHECKS: Click Here For More Information

Adobe Acrobat FileForm A

Adobe Acrobat File
Nursing License by Endorsement Application - for Out of State Applicants - SAMPLE ONLY - NOT FOR SUBMISSION - For applicants already licensed in another state and never having been licensed in Ohio. Includes information for foreign educated nurses.

Adobe Acrobat File Endorsement Application - Form B Transcript Authorization - SAMPLE ONY - for foreign-educated applicants

Adobe Acrobat FileFind Your Correct Nursing School Code Here

Adobe Acrobat File Apply Online


Advanced Practice Registered Nursing Forms

All licensure and certification applications must be completed online. Please go to the front page of the website and click the box "eLicense.Ohio.gov" to access the online applications. The "sample" applications on the web page are for reference only and are provided for informational purposes.

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.  Once we have started processing your application, your name will appear as “pending” until your license is issued.

ONLINE PAYMENTS: Fees must be paid online at the time of renewal. Use Master Card, VISA or Discover credit or debit cards. If you do not have this type of personal credit or debit card, you can obtain these pre-paid cards at local stores to use for renewal. If the fee is not paid when you submit your application, the application will be incomplete and will not be processed.

If you are mailing one of the secondary 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.

Adobe Acrobat FileMedical Clearance to Return to Play Form

Advanced Practice Registered Nurse (APRN) Forms

Adobe Acrobat FileAdvanced Practice Registered Nurse License Application - Sample Only Not for Submission

Adobe Acrobat FileCertificate of Authority Renewal / APRN License Application- Sample Only Not for Submission

Adobe Acrobat FileAdvanced Practice Registered Nurse License Renewal Application 2019 - Sample Only Not for Submission

Adobe Acrobat FileAdvanced Practice Registered Nurse License Reactivation and Reinstatement Application - Sample Only Not for Submission

Adobe Acrobat File 2016 Verification Form for Organizations Certifying Certified Nurse Midwives (CNMs), Certified Nurse Practitioners (CNPs), Clinical Nurse Specialists (CNSs), and Certified Registered Nurse Anesthetists (CRNAs) - Sample Only

Adobe Acrobat File Apply Online


Volunteer Certificate Forms

  Adobe Acrobat File Volunteer's Certificate Application - Sample Only
  Adobe Acrobat File Volunteer's Certificate Renewal Application - Sample Only
  Adobe Acrobat File Volunteer's Certificate Reactivation and Reinstatement Application - Sample Only



Alternative Program for Chemical Dependency

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  FAQs - Alternative Program for Chemical Dependency/Substance Use Disorders

 Adobe Acrobat File  Form C - Secondary Contact Form
    Adobe Acrobat File  Form F - Current Employer List
    Adobe Acrobat File  Form G - Treating Healthcare Practitioner List
    Adobe Acrobat File  Form H - Current Treatment/Aftercare/ Mental Health
    Adobe Acrobat File  Form I - Personal Report Form
    Adobe Acrobat File  Form J - Meeting Documentation
    Adobe Acrobat File  Form K - Probation/Diversion/Parole/Community Control Report
    Adobe Acrobat File  Form L - Work Performance Evaluation Form
    Adobe Acrobat File  Form P - Waiver for Release of Information from the Mental Health Provider
    Adobe Acrobat File  Form S - Employment History
    Adobe Acrobat File  Form T - Provider List
    Adobe Acrobat File  Form V - Waiver for Release of Information from the Treatment Provider
    Adobe Acrobat File  Form W - Progress Evaluation Form
    Adobe Acrobat File  Form X - Healthcare Provider Evaluation Form
    Adobe Acrobat File  Form Z - Participant Treatment Plan Form


  Adobe Acrobat File  Alternative Program Application - Sample Only



Compliance Post-Disciplinary Monitoring

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.


Nursing Education Program Related Forms

Education Program Annual Report Form Samples

  Adobe Acrobat File Education Program RN Annual Report Form (Sample)
  Adobe Acrobat File Education Program PN Annual Report Form (Sample)


Continuing Education Related Forms
 
  Adobe Acrobat File
OBN Approver Application (Sample)


Nursing Education Grant Program (NEGP) Forms

   Microsoft Word DocumentNEGP RFP Appendix-A Cover Sheet
   Microsoft Word DocumentNEGP RFP Appendix-B Budget Request Form
   Adobe Acrobat FileNEGP Quarterly Report Form
   Microsoft Word DocumentNEGP Quarterly Report Form (MS-Word Document Form)
   Microsoft Word DocumentNEGP Annual Report Form (MS-Word Document Form)
   Microsoft Word DocumentNEGP Final Report Form (MS-Word Document Form)


Adobe Acrobat File  (Back to Top of Page)

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