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 /Education Forms

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General Information

When a Payment is Required: 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.

Updated Licensure & Certification Applications

The Ohio Board of Nursing has updated all licensure and certification applications. The revised applications were effective 4/1/2013. Outdated Applications will not be accepted after 4/1/2013.

Name & Address Change Form

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


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)

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 FileMedication Aide Training Program Re-Approval Application (MS Word Format)


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)


Program Approval Forms

   Adobe Acrobat FileCommunity Health Worker Program Approval Application
   Adobe Acrobat FileCommu

nity Health Worker Training Program Re-Approval Application


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)

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    (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

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.

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 background check instructions that are attached to the 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 B Transcript Authorization- Only out of state exam applicants are required to submit Form-B 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 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 Packet for Out of State Applicants
   (Already Licensed in Another State and Never Having Been Licensed in Ohio)
Adobe Acrobat File   Endorsement Application - Form B Transcript Authorization for foreign-educated applicants

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 FileAlternative Program for Chemical Dependency Application - (Sample ONLY - Not for Submission)
  Adobe Acrobat FileAlternative Program for Chemical Dependency - FAQ

   Adobe Acrobat FileForm F - Current Employer List
   Adobe Acrobat FileForm G - Treating Healthcare Practitioner List
   Adobe Acrobat FileForm I - Personal Report
   Adobe Acrobat FileForm 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 

Other Education Related Forms

  Adobe Acrobat File  Nursing Education Program Dissatisfaction Form

     Adobe Acrobat File  Preceptor Form

      Adobe Acrobat File  Conditional Approval Program Report Form (MS-Word Document Template)

     Adobe Acrobat File  Guidelines for Certificate of Completion Forms
           Adobe Acrobat File  Sample Certificate of Completion Form RN
          Adobe Acrobat File  Sample Certificate of Completion Form LPN

Sample Only Forms

The forms below are provided as examples of the required forms provided on request by the Board. Due to our internal processes and their nature you must contact the Board directly to obtain a working copy of these particular application and forms.

  Adobe Acrobat FileRN Renewal Application - Sample
  Adobe Acrobat FileRN Renewal, Reactivation, Reinstatement Application - Sample
  Adobe Acrobat FileCertificate of Authority (COA) Renewal Application - Sample
  Adobe Acrobat FileCertificate of Authority (COA) Reactivation, Reinstatement Application - Sample
  Adobe Acrobat FileCertificate to Prescribe (CTP) Renewal Application - Sample
  Adobe Acrobat FileCertificate to Prescribe (CTP) Reactivation, Reinstatement Application - Sample
  Adobe Acrobat FileAnnual COA Verification form for Certifying Organizations - Sample
  Adobe Acrobat FileLPN Renewal Application - Sample
  Adobe Acrobat FileLPN Renewal, Reactivation, Reinstatement Application - Sample
  Adobe Acrobat FileLPN IV-Therapy Application - Sample
  Adobe Acrobat FileDialysis Technician Renewal Application- Sample
  Adobe Acrobat FileDialysis Technician Testing Organization Initial & Renewal Application - Sample     
  Adobe Acrobat FileCommunity Health Worker Renewal Application - Sample
  Adobe Acrobat FileMedication Aide Renewal Application - Sample
           


Adobe Acrobat File  (Top of Page)


Front Page | State of Ohio | Feedback | Contact Us | Last updated on: May 17, 2013

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