BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer CONTINUING EDUCATION PROVIDER FACT SHEET ALL APPLICANTS MUST PROVIDE THE FOLLOWING: i Application fee of $200 (check or money order) payable to the Board of Registered Nursing. i Completed Application for Approval as a Continuing Education Provider, including the Course Information form (page 3) and Instructor Information form (page 4). x x i Be sure to provide your Federal Employer Identification Number (FEIN), if you are a business or corporation, or your Social Security Number (SSN), if you are an individual and do not have a FEIN number. Failure to include this will delay processing of your application. If you are planning to offer an advanced pharmacology course to nurse practitioners and/or nursemidwives, contact CE Program staff to be sure your course meets BRN requirements. If you have any other questions about the Continuing Education Program, please call us at (916) 323-7588. A sample of the advertising flyer/brochure and the certificate of completion The time required to process a complete application is a minimum of four to six weeks. The application fee of $200 is an earned fee for evaluating your application. The fee is NOT refundable. ***IMPORTANT*** The Board of Registered Nursing requests that all BRN-approved continuing education (CE) providers permit persons whose licenses have been disciplined by the Board to attend continuing education courses because these persons may have difficulty finding approved CE courses within a geographic area or which meet certain time constraints. It has come to the Board of Registered Nursing’s attention that, at times, persons whose licenses have been disciplined (had the license to practice registered nursing surrendered, revoked, suspended, or placed on probation) have been denied the opportunity to take continuing education (CE) courses. Please note that the Board, with some exceptions, permits any person who has a license issued by the Board and whose license has subsequently been disciplined, to take CE courses. The exceptions are when the course has a direct patient care component and the disciplined license is in a revoked status, or is currently suspended from practice, or the person is on probation and enrollment in the course must be approved by the BRN. Persons with disciplinary action may need to present documented evidence to the Board verifying completion of CE courses in order to demonstrate current nursing knowledge. Such documentation may be needed by a petitioner for reinstatement of a registered nursing license or by a nurse on Board-imposed probation. The certificate to be issued to persons who have a license revoked or suspended after successful course completion can contain the name of the person without the initials “RN” and without an RN license number. For registered nurses with a license on probation, the initials “RN” and the license number can appear on the certificate. American LegalNet, Inc. www.FormsWorkFlow.com CONTINUING EDUCATION PROVIDER FACT SHEET (Cont.) THE FOLLOWING IS PROVIDED AS AN EXAMPLE OF THE REASONS APPROVAL MAY BE DELAYED OR DENIED: FEDERAL TAX IDENTIFICATION NUMBER ™ The Federal Tax Identification Number (FEIN) is missing. If you are a corporation, health facility, school, etc., use your FEIN; if you are not a corporation and do not have a FEIN, use your Social Security Number. COURSE INFORMATION ™ The Course Information page is incomplete for the following reason(s): i Title of the course is not stated. i Objectives are not stated using behavioral terminology. i Overview/description of the course is incomplete. i Overview/description of the course is not stated. i Type of offering (i.e. academic, workshop, in-service, home study, etc.) is not noted. i Teaching methods are not indicated. i The number of contact hours is not stated. i Content is not presented in a comprehensive topical outline format. i Course content does not reflect post RN licensure content. INSTRUCTOR INFORMATION i Instructor information has not been submitted. i Instructor information is incomplete. i Instructor license number, expiration date, and type have not been provided. ADVERTISEMENT ™ The sample flyer/brochure has not been submitted. ™ The sample advertising flyer/brochure that you submitted is not in compliance for the following reason(s): i Provider’s name, as officially on file with the BRN, is different or missing. i Provider statement, “Provider approved by the California Board of Registered Nursing, Provider # ______, for ___ Contact Hours” should appear verbatim. i The refund/cancellation policy in the event of non-attendance by the licensee needs to be stated. i A clear, concise description of the course content and/or objective(s) has not been provided. i Delete the term CEUs. CEUs are given by colleges and universities only; the correct term is CE contact hours or contact hours. CERTIFICATE OF COMPLETION ™ The sample certificate of completion has not been submitted. ™ The sample certificate of completion that you submitted in not in compliance for the following reason(s): i Provider’s name, as officially on file with the BRN, is different or missing. i Provider statement, “Provider approved by the California Board of Registered Nursing, Provider # ______, for ___ Contact Hours” should appear verbatim. i The retention statement regarding RN retaining the document for a period of 4 years after the course concludes is missing. i Delete the term CEUs. CEUs are given by colleges and universities only; the correct term is CE contact hours or contact hours. CEP App (rev 05/04) Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer APPLICATION FOR APPROVAL AS A CONTINUING EDUCATION PROVIDER FEE $200 FOR OFFICE USE ONLY Be sure to complete the entire application, including the Course Information and Instructor Information forms. Please type or print all entries. Provider No: Cashier No: Approval Period: 1. Provider/Business Name: 2. Phone No: Bus: Res: City: 3. Address: State: ZIP Code: Yes 4. Have you ever been a provider of continuing education for nurses in California? If yes, Provider Name: Provider No: No 5. Provider as a/an: Association Non-Profit Corporation Corporation Partnership Government Agency Individual Organized Health Care System University, College or School 6. Contact Person: Name: Phone No: 7. Tax ID Number: Select the one that applies and enter that number: Social Security No. (SSN): OR Federal Employer Identification No. (FEIN): 8. Individual Responsible for Record Keeping: Phone No: 9. Address of Record Storage: I certify under penalty of perjury under the laws of the State of California that I have read and understand the regulations in Article 5, Title 16, California Code of Regulations, and that all courses and instructors meet the requirements of those regulations. Signature: CEP App (rev 05/04) Date: Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer COURSE INFORMATION (California Code of Regulations, Title 16, Section 1456) Please Type or Print All Entries PROVIDER/BUSINESS NAME: 1. TITLE: 2. DATE(S) TO BE OFFERED: 3. OBJECTIVES (Behavioral Terminology): 4. OVERVIEW/DESCRIPTION: 5. TYPE OF OFFERING (Academic, Workshop, In-service, Independent study, etc.): 6. TEACHING METHODS: 7. NUMBER OF CONTACT HOURS: * 8. CONTENT (Outline Form): 9. METHOD OF EVALUATION WHEN REQUIRED: * Independent study providers describe methodology used to determine number of contact hours. CEP App (rev 05/04) Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer INSTRUCTOR INFORMATION (California Code of Regulations, Title 16, Section 1457) Please Type or Print All Entries 1. NAME: 2a. LICENSE NUMBER: 2b. Date of Expiration: 2c. Type of License: 3. EDUCATION: College/University Major Degree Area of Preparation Year Degree Granted 4. EXPERIENCE: (Start with most recent experience) Agency Position Clinical Area Description Location From Mo/Yr To Mo/Yr 5. TEACHING EXPERIENCE: Title of Course 6. Have you ever had a course in Principles of Adult Education? Yes Month/Year No If yes, give dates: _________________________________________________________________________ NOTE: If course has more than one instructor, please copy this form, as a separate form is necessary for each instructor. CEP App (rev 05/04) Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer CONTINUING EDUCATION PROVIDER CHECKLIST The following checklist may help you to be sure your application packet is complete. This will facilitate the timely processing of your application. Check to make sure you have: † Typed or clearly block-printed the application. † Completed every question on both the "Course Information" and "Instructor Information" page. † Indicated the FEIN (if you represent a corporation, health facility, governmental agency, etc.) or SSN if you are filing your application as a private citizen in box #7 on the first page of the application. † Included a sample of the advertising flyer/brochure and the certificate of completion. † Signed and dated the application. † Enclosed a check for $200 made out to the Board of Registered Nursing. Mail to: California Board of Registered Nursing ATTN: Continuing Education Program P.O. Box 944210 Sacramento, CA 94244-2100 CEP App (rev 05/04) Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 P (916) 322-3350 F (916) 574-8637 | www.rn.ca.gov Louise R. Bailey, MEd, RN, Executive Officer INFORMATION COLLECTION AND ACCESS The Information Practices Act, Section 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals. Agency Name: BOARD OF REGISTERED NURSING Title of official responsible for information maintenance: EXECUTIVE OFFICER Address: Telephone Number: P.O. BOX 944210, SACRAMENTO, CA 94244-2100 (916) 322-3350 Authority which authorizes the maintenance of the information: SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODE ALL INFORMATION IS MANDATORY. The consequences, if any of not providing all or any part of the requested information: FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THE APPLICATION BEING REJECTED AS INCOMPLETE. The principal purpose(s) for which the information is to be used: TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR SOCIAL SECURITY NUMBER WILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENT AND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USCA 405(c)(3)(C)) AUTHORIZE COLLECTION OF YOUR SOCIAL SECURITY NUMBER. IF YOU FAIL TO DISCLOSE YOUR SOCIAL SECURITY NUMBER, YOU WILL BE REPORTED TO THE FRANCHISE TAX BOARD, WHICH MAY ASSESS A $100 PENALTY AGAINST YOU. YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON REQUEST IF AND WHEN YOU BECOME LICENSED. Any known or foreseeable interagency or intergovernmental transfer which may be made of the information: POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES AND REPORTING SOCIAL SECURITY NUMBER TO THE FRANCHISE TAX BOARD OR FOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THE BUSINESS AND PROFESSIONS CODE. EACH INDIVIDUAL HAS THE RIGHT TO REVIEW THE FILES ON RECORDS MAINTAINED ON THEM BY THE AGENCY, UNLESS THE RECORDS ARE EXEMPT FROM DISCLOSURE. (Rev 1/07) American LegalNet, Inc. www.FormsWorkFlow.com MANDATORY REPORTER Under California law each person licensed by the Board of Registered Nursing is a “Mandated Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section 11166 and will comply with those provisions. California Penal Code Section 11166 requires that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 [generally law enforcement agencies] whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter must make a report to the agency immediately or as soon as is practicably possible by telephone, and the mandated reporter must prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. Failure to comply with the requirements of Section 11166 is a misdemeanor, punishable by up to six months in a county jail, by a fine of one thousand dollars ($1,000), or by both imprisonment and fine. For further details about these requirements, consult Penal Code Section 11164, and subsequent sections. (Rev 1/07) American LegalNet, Inc. www.FormsWorkFlow.com