Application for a Conditional Licence: Emergency

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.

Nursing Designation

CONTACT INFORMATION

Full Name
Mailing Address
(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. 

NURSE PRACTITIONER INFORMATION 

Initial NP Education
NP Clinical Practice Setting
NP Clinical Practice Setting
Please indicate focus in next question

RECORD OF NURSING EMPLOYMENT 

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
November 1 - October 31
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
Critical Care/ICU/Ventilator Management
Critical Care/ICU/Ventilator Management
Operating Room/Recovery
Operating Room/Recovery
Mental health/Grief management/Counseling
Mental health/Grief management/Counseling
Burn Management
Burn Management
Long term care/Palliative care
Long term care/Palliative care
Public health
Public health
Disaster management experience/training/ psychosocial response
Disaster management experience/training/ psychosocial response
Other area of nursing
Other area of nursing

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?

Have you ever pleaded no contest or made any similar plea to any criminal charge?

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?

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?

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?

Are you currently the subject of any complaint, investigation or other proceeding by any registration/licensing authority?

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?

Have you ever been disciplined by a registration/licensing authority for any occupation/profession?

Do you have any conditions or restrictions on any licence that you currently hold or have held in any occupation or profession?

Have you ever been denied or had revoked any occupational or professional registration, license or permit, which you have not previously reported to NSCN?

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?

Have you ever been suspended or terminated from any employment, which you have not previously reported to NSCN?

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?

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?

(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: 
  1. I am the person completing the application. 
  2. I attest that the information provided on the form is true and complete. 
  3. 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. 
  4. I consent to NSCN verifying any and all information, which may include contacting the employers, institutions or authorities cited in my application. 
  5. I understand NSCN will immediately stop the assessment of my application while they gather more information if: 
    1. I have provided any inaccurate information; or 
    2. I have omitted required information; or 
    3. NSCN determines that any documents submitted during the application process have been altered, tampered with or forged. 
  6. I further understand that should #5 occur, it may result in a delay or denial of my application. 
  7. I accept the NSCN’ Privacy Policy (NSCN.ca/privacy-policy). 
  8. 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. 
  9. 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.