SALPN Out of Province APPLICATION FOR · PDF fileSALPN – OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION FOR LICENSURE January 1, ... Is the English language ... Name of Nursing

SALPN – OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION FOR LICENSURE January 1, 2017 Page 1 of 5

SALPN Out of Province Licensed Practical Nurse

APPLICATION FOR LICENSURE

PERSONAL (Please Print)

________________________________ Current Legal Surname (Last Name)

__________________________________ Given Name (First Name)

_________________________________ Middle Name(s)

_________________________________

Maiden Name

__________________________________

Date of Birth (dd/mm/yy) Sex Female Male

______________________________________________________________________ Apartment / Box No. / Address or Street No.

_________________________________ City / Town / Village

_________________________________ Province/State

__________________________________ Country

_________________________________ Postal Code / Zip Code

_________________________________ Telephone No.

__________________________________ Cell No.

________________________________ Alternate

_________________________________________________________ E-mail Address (MANDATORY)

PERSONAL DECLARATION (check all applicable)

1. Have you ever applied for registration/licensure in Saskatchewan previously?

Yes No

2. Have you applied for registration/licensure in any Canadian province or territory? Yes No

3. Have you ever been denied registration/licensure by a registration/ licensing authority for nursing in Saskatchewan or any other health profession in Saskatchewan or any other province, territory, state or country (excluding SALPN)?

Yes No

4. Have you ever been subject to any investigative proceedings with respect to professional misconduct or incompetence in nursing by any regulatory body, in Saskatchewan or any other province, territory, state or country (excluding SALPN)?

Yes No

5. Are you currently under investigation or involved in any proceedings, which could or has resulted in the encumbrance, suspension, revocation or denial of your nursing registration by:

a. A registration/licensing authority for nursing LPN/RPN/RN in any province, territory, state or country?

Yes No

b. Another health profession (other than nursing) in any province, territory, state or country? Yes No

c. Any other profession in any province, territory, state or country? Yes No

6. Have you been charged with or convicted of a criminal offense? If yes, please explain and attach an updated Criminal Record Check (original copy)

Yes No

7. Have you pleaded guilty or been found guilty of a criminal offence for which a pardon has been granted?

Yes No


8. Do you have any physical or mental condition or disorder that may impair your ability to provide safe, competent and ethical care? If you have answered yes to question 8, answer the questions below; otherwise leave questions (a) and (b) blank.

Yes No

a. If “Yes”, are you under the care of a physician or healthcare team? Yes No

b. If “Yes”, are you following medical advice?

If any circumstances change throughout the year, you are required to contact SALPN.

Yes No

9. Is the English language your first learned language and is it the language you first Yes No

learned and understood in childhood for reading, writing, listening, and speaking. (if no, one of the following will be accepted: 1. IELTS test results

2. Evidence of completing a Canadian Practical Nursing program in English plus an additional two (2) years of full time study in

English in Canada. Full time study is defined as a minimum of three (3) classes per semester.

3. Evidence of completing four (4) years of full time study in English in Canada must be provided. Full time study is defined as

a minimum of three (3) classes per semester.

(Please Print: With the exception of #9, if you answered ‘YES’ to any question on the Personal Declaration, provide a brief explanation, add another page if needed)

NURSING EDUCATION (Please Print: Provide all nursing programs taken, including both basic and re-

entry programs.) Name of Nursing Program

Start Date

(dd/mm/yy)

Completion Date

(dd/mm/yy)

Credential Received (example; Degree, Diploma, Certificate)

Name of Educational Institution Address (Street No./City/Province/Country) Phone (including area code)

Name of Nursing Examination Number of Times Examination Written Passed

Yes No

ADDITIONAL NURSING EDUCATION (Please Print: Report all post basic programs and/or courses

completed. If more than 3, please provide on a separate piece of paper.) Name of Credential Received

Institution Name and Country Start Date and Completion

Date

Name of Credential Received

Institution Name and Country Start Date and Completion Date

Name of Credential Received

Institution Name and Country Start Date and Completion Date

INITIAL NURSING REGISTRATION (Please Print: Provide original registration information only,

even if registration is no longer current.)


Registration or Licensure Type (LPN, RN)

Registration or Licensure Status

Conditions/Limitations on Registration or Licensure (if applicable)

Province/State/ Country

Registration Licensure Number

Issued Date (dd/mm/yy)

Expiry Date (dd/mm/yy)

CURRENT/PAST NURSING REGISTRATION/LICENSURE (Provide all places of registration (other

than with SALPN) or other regulated profession(s) (i.e. registered nurse, physiotherapist, midwife, paramedic, etc.). If you are not currently registered then provide the most recent place of registration/licensure. If more than 2, please

provide on a separate piece of paper. Registration or Licensure Type (LPN, RN)

Registration or Licensure Status

Conditions/Limitations on Registration or Licensure (if applicable)

Province/State/ Country

Registration or Licensure Number

Issued Date (dd/mm/yy)

Expiry Date (dd/mm/yy)

NURSING EMPLOYMENT HISTORY (Please Print: Provide all employers in the past 5 years. If more

than 4, please provide on a separate piece of paper.) Employer Name and Phone Job Title/Position Address Unit/Area of Responsibility (check applicable

boxes) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term Care Pediatrics Other________________________________

Start Date (dd/mm/yy) Status (Full-Time, Part-Time, Casual)

Employer Name and Phone End date (dd/mm/yy)

Job Title/Position Address Unit/Area of Responsibility (check applicable boxes) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term Care Pediatrics Other________________________________



Job Title/Position Address Unit/Area of Responsibility (check applicable boxes)


Start Date (dd/mm/yy) Status (Full-Time, Part-Time, Casual) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term Care Pediatrics Other________________________________


Job Title/Position Address Unit/Area of Responsibility (check applicable boxes) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term

Care Pediatrics Other________________________________


ADDITIONAL APPLICATION REQUIREMENTS (You must also submit the following with your

application form or it may be considered incomplete, please verify.)

I have included a clear copy of my birth certificate, marriage certificate and/or valid passport. (Mail or Email; Do Not Fax)

I have included the $550.00 for the licensure fee, and the non-refundable application fee. (Visa/MasterCard payable on the credit

card authorization form, cheque, certified cheque or money order payable to SALPN. Please do not mail cash.

PRIVACY STATEMENT I acknowledge that the information contained in this form is being collected and will be used for the purpose of assessing my application for licensure. This information will be maintained on my file and may also be used to assess my application for renewal of my practicing renewal in the future or for the purpose of a discipline proceeding under the LPN Act, 2000. The information contained in this form will only be disclosed pursuant to the provisions in the LPN Act, 2000, the Personal Information Protection Act, as otherwise required by law, unless your consent to disclose the information has been obtained. CONSENT TO REVOCATION/SUSPENSION OF LICENSURE I acknowledge and agree that the SALPN may, at its option, immediately revoke, suspend or refuse to renew my licensure if any information contained in this application is inaccurate or incomplete until such that the SALPN has had the opportunity to reconsider my application. I agree to provide any additional information that may be required by the SALPN to consider my application for licensure. I agree to return my licensure to the SALPN as requested in the event that my licensure is revoked or suspended. I also acknowledge and agree that I may be subject to disciplinary action, irrespective of whether my licensure is revoked or suspended with the SALPN, if I fail to provide current, correct and complete information to the SALPN in respect to my application for licensure. LICENSURE DECLARATION I declare that all of the information on this form is current, correct and complete. I declare that all documents submitted with this application to the SALPN are authentic true originals or true copies of original documents. I declare that I am of good character and am fit to practice, consistent with the responsibilities, ethics and standards expected of a Licensed Practical Nurse. I hereby certify that I am the person making application for licensure as a Licensed Practical Nurse in Saskatchewan and that all statements are true and complete in every respect. I understand that omission, inaccuracy, and falsification of information on this application may result in the cancellation of my application for licensure or cancellation of any licensure, which may be issued. I understand that my application for assessment of eligibility and/or licensure is considered lapsed if required documentation is not received in the SALPN office and I have not obtained licensure within 6 months from my application date. I understand that after 6 months have lapsed I am required to reapply.


________________________________________________ Applicant Signature (do not print)

_______________________________________________________ Date (dd/mm/yy)

SALPN – Out of Province Licensed Practical Nurse Competency Self-Checklist January 1, 2017 Page 1 of 1


COMPETENCY SELF-CHECKLIST

Please indicate with a checkmark if the following competencies were part of your basic nursing education, post-

basic education or employer delivered education and send directly to the SALPN.

Competency Basic

Education

Post Basic

Education

Employer Delivered

Education Health Assessment

(indicate length of course)

Admin of Meds

(without narcotics)

Admin of Meds

(with narcotics)

Subcutaneous Injections

IM injections

Maintenance of peripheral IV

Initiating peripheral IV

Initiating Blood & Blood

products

Physician orders

(taking and trancribing)

Central Lines

(theory)

Name - Print Signature

OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF EMPLOYMENT January 1, 2017 Page 1 of 2

SALPN OUT OF PROVINCE LICENSED PRACTICAL NURSE

DECLARATION OF EMPLOYMENT HOURS

Complete Section 1 for all employers in the past 5 years. If you have more than 2 employers, please print additional forms.

SECTION 1 (completed by applicant)


____________________________________ Current Legal Surname (Last Name)

_____________________________________ Given Name (First Name)

____________________________________ Middle Name(s)

____________________________________ Maiden Name

_____________________________________ Date of Birth (dd/mm/yy)

Sex Female Male

____________________________________________________________________________ Apartment / Box No. / Address or Street No.

____________________________________ City / Town / Village

____________________________________ Province/State

_____________________________________ Country

____________________________________ Postal Code / Zip Code

_____________________________________ Telephone No.

_____________________________________ Cell No.

_____________________________________ Alternate Phone Number

__________________________________________________________ E-mail Address

EMPLOYMENT DETAILS (Please Print)

Facility Name

__________________ Start Date (dd/mm/yy)

__________________ End Date (dd/mm/yy)

______________________________ Job Title/Position

Unit/Area of Responsibility (check applicable boxes)

Medical Mental Health/Psychiatry

Surgical Community

Obstetrics Pediatrics

Gerontology/Long Term Care

Other________________________________

___________________________________ Supervisor Name

___________________________________ Supervisor Job Title/Position

EMPLOYMENT HOURS

Year Employed Total Hours Worked

2016

2015

2014

2013

2012

OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF EMPLOYMENT January 1, 2017 Page 2 of 2

EMPLOYMENT DETAILS (Please Print)

Facility Name

__________________ Start Date (dd/mm/yy)

__________________ End Date (dd/mm/yy)

______________________________ Job Title/Position

Unit/Area of Responsibility (check applicable boxes)

Medical Mental Health/Psychiatry

Surgical Community

Obstetrics Pediatrics

Gerontology/Long Term Care

Other________________________________

___________________________________ Supervisor Name

___________________________________ Supervisor Job Title/Position

EMPLOYMENT HOURS

Year Employed Total Hours Worked

2016

2015

2014

2013

2012

SECTION 2 - Declaration

The information contained on this Declaration of Employment Hours form is true and correct to the best of my knowledge. I understand that the SALPN may request a verification from my previous or current employers at their discretion. I understand that falsification of information provided on this application form may be considered professional misconduct as per the LPN Act, 2000. Signature:________________________________________ Date:____________________________________

OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF REGISTRATION/LICENSURE January 1, 2017 Page 1 of 1


VERIFICATION OF REGISTRATION/LICENSURE

Part B (to be completed and certified by the Registrar or Designate and sent directly to the SALPN)

I do certify that Name of Applicant Maiden

Graduate from Located in School of Nursing Province/State/Country Graduated with: Certificate Diploma Degree Completion Date Registration Number Issued on MM/DD/YY

Applicant was registered by: Examination Endorsement

Examination written: CPNRE NCLEX Other (specify)

Examination Date: Pass Fail Number of times written: Registration Status: Practicing Non-Practicing Other Is the Registrant’s Registration/Licensure currently or ever had a history of being revoked, suspended, surrendered, restricted or subjected to individual terms and conditions? Is the Applicant eligible for renewal? Yes No If no, please indicate why: Signature of Registrar of Designate Date SEAL Jurisdiction

Part A (to be completed by Applicant)

Name First Last Middle Maiden Address Street City Province Postal Code

I authorize the jurisdiction of to complete this form.

Applicant Signature Date

OUT OF PROVINCE LICENSED PRACTICAL NURSE SPECIALIZED PRACTICE DECLARATION January 1, 2017 Page 1 of 3


SPECIALIZED ADVANCED AREA OF PRACTICE DECLARATION


________________________________ Current Legal Surname (Last Name)

_________________________________ Given Name (First Name)

__________________________________ Middle Name(s)

________________________________ Maiden Name

_________________________________ Date of Birth (dd/mm/yy)

Sex Female Male

____________________________________________________________________ Apartment / Box No. / Address or Street No.

__________________________________ City / Town / Village

________________________________ Province/State

__________________________________ Country

__________________________________ Postal Code / Zip Code

________________________________ Telephone No.

__________________________________ Cell No.

___________________________________ Alternate Telephone Number

__________________________________________________________ E-mail Address (mandatory)

SPECIALIZATION INFORMATION The SALPN has identified Specialized Areas of LPN Practice which require a level of professional competence to be performed safely. Regulated professionals must be authorized by the SALPN to perform in Specialized Areas of LPN Practice. There are three Specialized Areas of LPN Practice that are monitored by the SALPN. The LPN must be granted authority by the SALPN to engage in Specialized Areas of LPN Practice in the following areas:

Advanced Orthopedics Perioperative Nursing Hemodialysis

There are differences in the education for these three Specialized Practice areas.

Approved education must be achieved in Advanced Orthopedics, Perioperative Nursing, and Hemodialysis.

Please indicate if you wish to have equivalency assessed in Advanced Orthopedics, Perioperative, Hemodialysis by completing the Declaration of Specialization and requesting original educational transcripts and/or certificates to be sent to the SALPN. If you do not have a specialized practice area of practice, you are not required to complete this form. Once your specialization is approved by the SALPN, it will be indicated on your licensure and will be displayed on the Public Registry.

OUT OF PROVINCE LICENSED PRACTICAL NURSE SPECIALIZED AND/OR ADVANCED AREA of PRACTICE DECLARATION January 1, 2017 Page 2 of 3

ADVANCED FOOTCARE INFORMATION

The SALPN has identified Advanced Footcare as an advanced competency. This advanced area requires a level of professional competence to be performed safely. Regulated professionals must be authorized by the SALPN to perform in Advanced Footcare.

Approved education must be achieved in Advanced Footcare before practice in this area begins.

Please indicate if you wish to have equivalency assessed in Advanced Footcare by completing the Declaration of Specialization/Advanced Practice and requesting original educational transcripts and/or certificates to be sent to the SALPN. If you do not have additional education in Advanced Footcare, you are not required to complete this form. Once approved by the SALPN, the Advanced Footcare competency will be indicated on your licensure and displayed on the SALPN

Public Registry.

DECLARATION OF SPECIALIZATION AND/OR ADVANCED AREA OF PRACTICE (Please Print: check applicable boxes)

Specialization and/or Advanced Area of Practice

Educational Facility Completion Date Original Transcript or Certificate Submitted

Advanced Orthopedics

(specialized)

Perioperative

(specialized)

Hemodialysis

(specialized)

Footcare (advanced area

of practice)

DECLARATION I hereby declare that I am the person making application for registration as a Licensed Practical Nurse in Saskatchewan and that all statements are true and complete in every respect. I understand that falsification of information on this application may result in the cancellation of my application for licensure or cancellation of any licensure, which may be issued.

____________________________________________________ Signature of Applicant (do not print)

______________________________________________________ Date

OUT OF PROVINCE LICENSED PRACTICAL NURSE SPECIALIZED AND/OR ADVANCED AREA of PRACTICE DECLARATION January 1, 2017 Page 3 of 3

FOR OFFICE USE ONLY Date

Approval

Comments

Alinity Entry Date

OUT OF PROVINCE LICENSED PRACTICAL NURSE CREDIT CARD AUTHORIZATION FORM January 1, 2017 Page 1 of 1


CREDIT CARD AUTHORIZATION FORM

PAYMENT INFORMATION (please print)

Date: Amount: $550.00

Payment

Description: OUT OF PROVINCE APPLICATION FEE - $150.00

OUT OF PROVINCE LICENSURE FEE - $400.00

PERSONAL INFORMATION (please print)

Name:

Address:

City: Province: Postal Code:

Phone: Cell:

Email:

CREDIT CARD INFORMATION (please print)

Cardholder Name:

Credit Card #:

Expiry Date: Month: Year: Credit Card: VISA MasterCard

Signature: Date:

Documents

SALPN Out of Province APPLICATION FOR · PDF fileSALPN – OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION FOR LICENSURE January 1, ... Is the English language ... Name of Nursing