Forms Page Shortcuts: Name and Address Changes / 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 /Education Forms / Sample Forms

PDF Format Download the free Adobe Acrobat Reader to view the PDF documents below.

General Information

Online payments:

Fees must be paid online. 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.

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


Name & Address Changes

Managing Your License and Certificate Online

Begining 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 & Address Change Form (For All License & Certificate Holders) - No longer accepted - SAMPLE ONLY



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    (Top of Page)

The Ohio Department of Administrative Services (DAS/OIT) and its vendor are implementing a NEW 3.0 Ohio eLicense system that will eventually accommodate most of Ohio’s professional licensing boards. The Nursing Board is engaged in the system conversion at this time. With over 280,000 Nursing Board licensees, this transition and migration of data is extremely difficult and time-consuming. The challenge includes security and technical requirements resulting in DAS/OIT and the vendor temporarily stopping operations of the Board’s current licensing system.

The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for licensure will be received and processed on-line. We apologize for the inconvenience, but we expect that the upgrades will significantly enhance the Board’s service capabilities in the future.

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.

   Adobe Acrobat FileMedication Aide Application Packet - SAMPLE ONLY - NOT FOR SUBMISSION
   Adobe Acrobat FileMedication Aide Application - Form A

Adobe Acrobat File Apply Online
 
Program Approval Forms

Adobe Acrobat FileMedication Aide Training Program Application

Adobe Acrobat FileMedication Aide Training Program Application (MS Word Format)

Adobe Acrobat FileMedication Aide Training Program Re-Approval Application

Adobe Acrobat File
Medication Aide Training Program Re-Approval Application (MS Word Format)

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



Community Health Workers    (Top of Page)

The Ohio Department of Administrative Services (DAS/OIT) and its vendor are implementing a NEW 3.0 Ohio eLicense system that will eventually accommodate most of Ohio’s professional licensing boards. The Nursing Board is engaged in the system conversion at this time. With over 280,000 Nursing Board licensees, this transition and migration of data is extremely difficult and time-consuming. The challenge includes security and technical requirements resulting in DAS/OIT and the vendor temporarily stopping operations of the Board’s current licensing system.

The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for licensure will be received and processed on-line. We apologize for the inconvenience, but we expect that the upgrades will significantly enhance the Board’s service capabilities in the future.

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.

   Adobe Acrobat File Community Health Worker Application Packet - SAMPLE ONLY - NOT FOR SUBMISSION
   Adobe Acrobat File Community Health Worker Application - Form A

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)

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



Dialysis Technicians    (Top of Page)

The Ohio Department of Administrative Services (DAS/OIT) and its vendor are implementing a NEW 3.0 Ohio eLicense system that will eventually accommodate most of Ohio’s professional licensing boards. The Nursing Board is engaged in the system conversion at this time. With over 280,000 Nursing Board licensees, this transition and migration of data is extremely difficult and time-consuming. The challenge includes security and technical requirements resulting in DAS/OIT and the vendor temporarily stopping operations of the Board’s current licensing system.

The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for licensure will be received and processed on-line. We apologize for the inconvenience, but we expect that the upgrades will significantly enhance the Board’s service capabilities in the future.

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.

   Adobe Acrobat FileDialysis Technician Application Packet - SAMPLE ONLY - NOT FOR SUBMISSION
   Adobe Acrobat FileDialysis Technician Application - Forms A, B, C & D

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 

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



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

The Ohio Department of Administrative Services (DAS/OIT) and its vendor are implementing a NEW 3.0 Ohio eLicense system that will eventually accommodate most of Ohio’s professional licensing boards. The Nursing Board is engaged in the system conversion at this time. With over 280,000 Nursing Board licensees, this transition and migration of data is extremely difficult and time-consuming. The challenge includes security and technical requirements resulting in DAS/OIT and the vendor temporarily stopping operations of the Board’s current licensing system.

The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for licensure will be received and processed on-line. We apologize for the inconvenience, but we expect that the upgrades will significantly enhance the Board’s service capabilities in the future.

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.

   Adobe Acrobat FileAffidavit of Lost Document - SAMPLE ONLY - NOT FOR SUBMISSION
   Adobe Acrobat FileReactivation and Reinstatement of a Nursing License - SAMPLE ONLY - NOT FOR SUBMISSION  

Adobe Acrobat File Apply Online

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



Nurse Licensure by Examination and Endorsement
   (Top of Page)

Important Information for Examination and Endorsement Applicants

ALL APPLICANTS: The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion to the new State of Ohio eLicense 3.0 system is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for certification and licensure must be submitted through the online portal.

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: Mastercard, Visa and Discover are accepted.

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 FileExamination Application Packet- 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 Apply Online

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

    Adobe Acrobat FileOhio Nursing Education Programs - School Code List
    Adobe Acrobat FileScheduling and Rescheduling Your NCLEX Examination
    Adobe Acrobat FileAccommodations for the NCLEX Examination
    Adobe Acrobat FileThe Eight Steps of the NCLEX (NCSBN Article)


Forms for Nurse Applicants (Already Licensed in Another State)

Endorsement Applicants: Complete Form A (enclosed) 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.

Adobe Acrobat File Endorsement Application Checklist

Adobe Acrobat File
Endorsement Application Packet 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- for foreign-educated applicants

Adobe Acrobat FileFind Your Correct Nursing School Code Here

Adobe Acrobat File Apply Online

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

We appreciate your patience.


Advanced Practice Nursing    (Top of Page)

ALL APPLICANTS: The Board has been unable to license new nursing program graduates or process any other license and certification applications since June 17, 2016. This stoppage will remain in effect until the conversion to the new State of Ohio eLicense 3.0 system is completed. The conversion is expected to be complete on July 1, 2016. When completed, all applications for certification and licensure must be submitted through the online portal.

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: Mastercard, Visa and Discover are accepted.

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

Certificate of Authority Forms

Adobe Acrobat File Certificate of Authority Application Packet - SAMPLE ONLY - NOT FOR SUBMISSION

Adobe Acrobat File Apply Online *Notarized signatures are no longer required for licensure and certification applications.


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 Apply Online

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

Adobe Acrobat FileCTP - Form A

Adobe Acrobat FileCTP - Form A 500 Hour

Adobe Acrobat FileCTP - Form B 500 Hour

Adobe Acrobat FileCTP - Form B 1500 Hour

Out of State Applicants (Please select the application below that applies to you.)
   
Adobe Acrobat FileCTP (Out of State Only) - SAMPLE ONLY - NOT FOR SUBMISSION -Complete this application if you currently hold a certificate to prescribe in another jurisdiction that includes the authority to prescribe controlled substances.
  
Adobe Acrobat FileCTP (Out of State Only) - SAMPLE ONLY - NOT FOR SUBMISSION -Complete this application if you currently hold a certificate to prescribe in another jurisdiction that does NOT include prescribing controlled substances. 

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



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 FileFAQs - Alternative Program for Chemical Dependency/Substance Use Disorders

Adobe Acrobat FileForm C - Secondary Contact Form

Adobe Acrobat FileForm F - Current Employer List

Adobe Acrobat FileForm G - Treating Healthcare Practitioner List

Adobe Acrobat FileForm H - Current Treatment/Aftercare/ Mental Health

Adobe Acrobat FileForm I - Personal Report Form

Adobe Acrobat FileForm J - Meeting Documentation

Adobe Acrobat FileForm K - Probation/Diversion/Parole/Community Control Report

Adobe Acrobat FileForm L - Work Performance Evaluation Form

Adobe Acrobat FileForm P - Waiver for Release of Information from the Mental Health Provider

Adobe Acrobat FileForm S - Employment History

Adobe Acrobat FileForm T - Provider List

Adobe Acrobat FileForm V - Waiver for Release of Information from the Treatment Provider

Adobe Acrobat FileForm W - Progress Evaluation Form

Adobe Acrobat FileForm X - Healthcare Provider Evaluation Form

Adobe Acrobat FileForm Z - Participant Treatment Plan Form

Adobe Acrobat FileAlternative Program Application - Sample



Compliance 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.


Nursing Education Program Related Forms

Education Program Pre-Survey Visit 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)


Nursing Education Grant Program (NEGP) Forms

   Adobe Acrobat FileNEGP RFP Appendix-A Cover Sheet
   Adobe Acrobat FileNEGP 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)


Sample Only Forms

The forms below are sample copies. Please send a written request for a copy of the form you are interested in obtaining by email to: renewal@nursing.ohio.gov (renewal forms); or by fax at (614) 466-0388, or by mailing the request to the Board. Telephone requests will not be accepted.

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

  Adobe Acrobat File RN Renewal Application - Sample

  Adobe Acrobat File RN-1 Renewal Application - Sample
  Adobe Acrobat File
RN-2 Renewal Application - Sample
  Adobe Acrobat File RN-3 Renewal Application - Sample
  Adobe Acrobat File RN Reactivation and Reinstatement Application - Sample

  Adobe Acrobat File Certificate of Authority (COA-NA) Renewal Application - Sample
  Adobe Acrobat File Certificate of Authority (COA-NP) Renewal Application - Sample
  Adobe Acrobat File Certificate of Authority (COA-NS) Renewal Application - Sample
  Adobe Acrobat File Certificate of Authority (COA-NM) Renewal Application - Sample
  Adobe Acrobat File Certificate of Authority (COA) Reactivation and Reinstatement Application - Sample

  Adobe Acrobat File Certificate to Prescribe (CTP) Renewal Application - Sample
  Adobe Acrobat File Certificate to Prescribe (CTP) Reactivation and Reinstatement Application - Sample
  Adobe Acrobat File Annual COA Verification form for Certifying Organizations - Sample

  Adobe Acrobat File Community Health Worker Renewal Application - Sample
  Adobe Acrobat File Community Health Worker (CHW) Reactivation and Reinstatement Application - Sample

  Adobe Acrobat File LPN Renewal Application - Sample
  Adobe Acrobat File LPN Reactivation and Reinstatement Application - Sample
  Adobe Acrobat File LPN IV-Therapy Application - Sample

  Adobe Acrobat File Dialysis Technician, Renewal Application - Sample
  
Adobe Acrobat File Dialysis Technician, Reactivation and Reinstatement Application - Sample
  Adobe Acrobat File Dialysis Technician Testing Organization Initial & Renewal Application - Sample
    
  Adobe Acrobat File Medication Aide, Renewal Application - Sample
  Adobe Acrobat File Medication Aide Reactivation and Reinstatement Application - Sample
    

Adobe Acrobat File  (Top of Page)

Front Page | State of Ohio | Feedback | Contact Us | Last updated on: July 19, 2016

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