Kentucky Board of Nursing


SELF-REPORT FORM


If self-reporting a conviction or disciplinary action on any professional license/certification or your privilege to practice in any state(s)/jurisdiction(s) you must submit mail or fax court or discipline records and a detailed letter of explanation to the Kentucky Board of Nursing office.
 
Self-Report Form
*Your First Name:
 
Your Middle Name:
*Your Last Name:
*Your SSN:
 
*Your Date of Birth:
mm/dd/yyyy  
*Your Home Address:
 
*City:
 
*State:
 
*Zip Code:
 
Your Day Phone:
Your Work Phone:
Your Email (may be verified):
 
Your Nursing License Number:
Your DEA Number:
*Employment Status:
 
Date of Resignation/ Suspension/ Termination:
mm/dd/yyyy
Your Current/Previous Employer:
 
Employer Address:
City:
State:
Zip Code:
Employer Phone:
Contact Person:
Employer Email:
 
Your Position/Title:
*Description stating the exact nature of your self report:
 
*Were there any witness(es)?  
Contact information of the witness(es) to the occurence(s):
 
*Has this information been reported to any other organization, law enforcement agency, or regulatory agency?  
If so, with whom?
 
*By typing my full name, I hereby declare and affirm under the penalties of perjury that the matters of facts set forth in the foregoing self-report are true and correct to the best of my knowledge, information, and belief:
 
 
If self-reporting a conviction or disciplinary action on any professional license/certification or your privilege to practice in any state(s)/jurisdiction(s) you must submit mail or fax court or discipline records and a detailed letter of explanation to the Kentucky Board of Nursing office.
Kentucky Board of Nursing - ADDRESS

Kentucky Board of Nursing
Attn: Consumer Protection Branch
312 Whittington Parkway, Suite 300
Louisville, KY 40222
Fax: 502-429-3353