Nurses who are currently registered and licensed in Nova Scotia do not need to apply for new or additional licensure in order to assist during the COVID-19 outbreak. Check this box to confirm you do NOT currently hold a practising licence in Nova Scotia. If you do, you do not need new or additional licensure to assist during the COVID-19 outbreak. Click here for more information. Nursing Designation Licensed Practical Nurse (LPN) Registered Nurse (RN) Nurse Practitioner (NP) CONTACT INFORMATION Full Name First Middle Surname Mailing Address Address Address 2 City/Town State/Province ZIP/Postal Code Country Telephone - Home Telephone - Work (with extension) Email NS Registration Number Date of Birth (mm/dd/yyyy) Previous Names Identify Language(s) (other than English) in which you currently have the ability to safely provide nursing services. ENTRY/INITIAL NURSING EDUCATION PREPARATION Indicate nursing education program that led to your initial registration. Diploma Baccalaureate Master Started (mm/yyyy) Graduated (mm/yyyy) Province or Country of Graduation NURSE PRACTITIONER INFORMATION Initial NP Education Diploma Baccalaureate Master Doctorate Prior Learning Assessment and Recognition (PLAR) None of the above NP Clinical Practice Setting NP Clinical Practice Setting Primary care/Family practice clinic Hospital-inpatient Please indicate focus in next question Hospital-outpatient/CEC/ER/Ambulatory care Long Term Care Other… Other: Indicate hospital-inpatient NP focus (e.g. cardiology, oncology) RECORD OF NURSING EMPLOYMENT Practice Hours? Year? NCLUDE NAMES OF ALL NURSING EMPLOYER(S) PROVINCE/ TERRITORY/ STATE/COUNTRY ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN LPN (and LPN conditional licence) ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN RN (and RN conditional licence) ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN NP (and NP conditional licence) Operations Year? November 1 - October 31 NCLUDE NAMES OF ALL NURSING EMPLOYER(S) PROVINCE/ TERRITORY/ STATE/COUNTRY ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN LPN (and LPN conditional licence) ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN RN (and RN conditional licence) ACTUAL NUMBER OF HOURS IN THE PRACTICE OF AN NP (and NP conditional licence) Add Add more items more items EMERGENCY PREPAREDNESS An emergency is defined as any situation or occurrence of a serious nature, developing suddenly and unexpectedly, and demanding immediate action. In the event of an emergency, (e.g., pandemic or disaster), it is often necessary to identify experienced nurses who can be contacted and deployed rapidly. Indicate if you would like to volunteer, and note your specific skills. I wish to volunteer in the event of an emergency in Nova Scotia that requires quick recruitment of qualified nurses. I have specific education/skills in the following area(s) within the past 10 years: Emergency/Trauma/Triage Emergency/Trauma/Triage ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Critical Care/ICU/Ventilator Management Critical Care/ICU/Ventilator Management ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Operating Room/Recovery Operating Room/Recovery ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Mental health/Grief management/Counseling Mental health/Grief management/Counseling ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Burn Management Burn Management ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Long term care/Palliative care Long term care/Palliative care ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Public health Public health ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Disaster management experience/training/ psychosocial response Disaster management experience/training/ psychosocial response ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA EXPERIENCE (# OF YEARS) EXPERIENCE (# OF YEARS) Emergency Prepardedness - Other area of nursing, please specify: Other area of nursing Other area of nursing ADULT PEDIATRIC NEONATAL CURRENTLY WORKING IN THIS AREA AREA OF NURSING AND EXPERIENCE (# OF YEARS) AREA OF NURSING AND EXPERIENCE (# OF YEARS) SCREENING/JUDICIAL QUESTIONS Answer the following questions based on your conduct both within and outside Canada. If you answer ‘yes’ to any of the following questions, please provide an explanation in space below. Have you ever been charged with, pleaded guilty to, been convicted of or found to be guilty of an offence, for which you have not received a pardon, including alcohol and drug related offenses but excluding parking, speeding or similar minor motor vehicle offences that do not involve substance use? Yes No Have you ever pleaded no contest or made any similar plea to any criminal charge? Yes No Have you ever been charged with or accused of a criminal offence that resulted in you entering into a diversion program, curative discharge or other resolution process as an alternative to conviction or prosecution? Yes No Has there ever been any civil proceeding, legal action, insurance or other claim that was in any way related to your practice of nursing or your professional activities, which you have not previously reported to NSCN? Yes No Is there now, or are you aware of any pending civil proceedings, legal actions, insurance or other claims that are in any way related to your practice of nursing or your professional activities, which you have not previously reported to NSCN? Yes No Have you ever agreed to a settlement as a means to resolve civil proceedings or in relation to any investigation, proceeding or disciplinary action with respect to your professional conduct, competence, character, capacity or fitness to practice, which you have not previously reported to NSCN? Yes No Are you currently the subject of any complaint, investigation or other proceeding by any registration/licensing authority? Yes No Have you ever, before or during the course of an investigation or disciplinary proceeding, voluntarily entered into an undertaking or otherwise agreed to restrict your practice or to refrain from practice? Yes No Have you ever been disciplined by a registration/licensing authority for any occupation/profession? Yes No Do you have any conditions or restrictions on any licence that you currently hold or have held in any occupation or profession? Yes No Have you ever been denied or had revoked any occupational or professional registration, license or permit, which you have not previously reported to NSCN? Yes No Were you ever the subject of an investigation, disciplined by or expelled from any university or school of nursing, which you have not previously reported to NSCN? Yes No Have you ever been suspended or terminated from any employment, which you have not previously reported to NSCN? Yes No In addition to the above, is there, to your knowledge or belief, any event, circumstance or condition concerning your competence, character, capacity, conduct or reputation that may impact your registration and ability to practice safely? Yes No For Nurse Practitioners Only: Do you have any Health Canada Notices (circular letters) related to prescribing controlled drugs and substances, which you have not previously reported to NSCN? Yes No EXPLANATION (Requested if you answered, ‘Yes’ to any of the screen/judicial questions) VERIFICATION/SIGNATURE Subject to the NSCN Privacy Policy that authorizes the release of certain information, by submitting this application form, I confirm that: I am the person completing the application. I attest that the information provided on the form is true and complete. I will immediately report to NSCN should anything occur while licensed that would alter my responses to any of the questions contained in this application. I consent to NSCN verifying any and all information, which may include contacting the employers, institutions or authorities cited in my application. I understand NSCN will immediately stop the assessment of my application while they gather more information if: I have provided any inaccurate information; or I have omitted required information; or NSCN determines that any documents submitted during the application process have been altered, tampered with or forged. I further understand that should #5 occur, it may result in a delay or denial of my application. I accept the NSCN’ Privacy Policy (NSCN.ca/privacy-policy). I understand that any and all information provided by me to NSCN in the course of the application process may be used internally by NSCN for any of its regulatory functions. I confirm that I have disclosed in this application all events, circumstances, or conditions concerning my capacity, competence, character, conduct or reputation that may impact my ability to safely and ethically practice nursing. I consent to sharing my contact information as part of the emergency response plan. Submit
