Required Documentation
Disclosure of arrest, citation, summons, warrant, charges, indictment:
1. Student’s detailed statement regarding the incident including date, names of
arresting/citing agencies, and current status of any pending legal action.
2. CERTIFIED TRUE COPIES of the following:
- Arrest/investigative report(s), citation, summons, warrants, indictments
- All court minutes, judgments and sentencing, or court orders
- Pretrial Intervention program agreements and letters of completion of all requirements
- Release from probation, and other relevant records to show resolution of the case.
Disclosure of action taken against practice nursing or as another health care provider:
1. Student’s detailed statement regarding the circumstances that lead to the action, the
current status of the action, any other information relevant to the disclosure.
2. CERTIFIED TRUE COPIES of the following:
- Other board actions
- Letters of current standing of licensure
Disclosure of other than honorable military discharge:
1.
Student’s detailed statement regarding the circumstances that lead to the discharge and current
status of any pending charges/preceding(s).
2. CERTIFIED TRUE COPIES of the following:
- Military discharge documents
- Documentation of the underlying action(s) that resulted in discharge
Disclosure of medical / physical / mental / emotional / psychiatric condition:
1. Student’s detailed statement regarding the disclosed condition including the date that
the condition was diagnosed and what treatment has been sought for the condition,
and list all medications prescribed.
2. Have diagnosing and/or treating professional complete the Clinical Nursing Student Medical-Mental
Condition Diagnostician / Treating Provider Form and include any medical/treatment records relevant
to the disclosed condition.
Disclosure of dependence / addiction to mood-altering substances:
1. Student’s detailed statement including a history of the dependence including substances
used/abused, treatment, and current date of sobriety.
2. Enclose all substance abuse treatment records, documentation of sobriety, and letter(s) from any
licensed professionals that are providing treatment relative to your dependence/addiction
that can address your current status in recovery and ability to safely practice nursing.
This disclosure form is ONLY
to be completed by clinical nursing students that have
previously been approved by LSBN and are currently enrolled in a clinical Nursing
course. All others will not be reviewed or processed.
2
STU 04 Rev 6/24/14, 1/5/1, 1/22/16, 3/31/16. 7/25/16 PAD
