RN Refresher Course Application - SDState

Continuing Nursing Education RN Independent Study Refresher Course Enrollment Application

Name: __________________________________________________________________________________________

Address: ________________________________________________________________________________________

City: ______________________________________________________ State: ____________ Zip: ________________

Email: ____________________________________________ Birth date:

Primary Phone: _____________________________________ Alternate: _____________________________________

Have you been a resident of the United States for the last seven years?

Yes

No

If no, please provide a brief residential history for this period. City and Country is required.

____________________________________________________________________________________________

Are you a citizen of the United States?

Yes

No

If no, do you hold a current Green Card?

Yes

No

If no, please indicate the country in which you are a registered citizen. __________________________________

Enrollment Information

1. Highest degree of education earned in Nursing: -- select --

2. Have you been a student enrolled in the SDSU RN Refresher Course before? Yes

No

If yes, what year did you enroll? ____________________

3. Inactive in Nursing for -- select -- years.

4. Are you fulfilling the requirements of a Board Order, Consent Agreement

Yes

No

or other Board of Nursing disciplinary action?

5. Do you hold an active RN license?

Yes

No

If yes, are you seeking to refresh knowledge and clinical skills?

Yes

No

6. Do you hold an inactive RN License?

Yes

No

If yes, are you applying for:

reinstatement

endorsement

If yes, in which state? -- select --

7. Not previously licensed?

Yes

NA

If yes, have you successfully completed the NCLEX exam?

Yes

No

If yes, please include verification of this completion with your application.

If no, participants that have not successfully completed the NCLEX exam may be admitted to the Independent

Study Refresher Course. However, the NCLEX exam must be successfully completed prior to receiving approval to

begin the clinical component of the course. _______ I have read and understand this requirement.

8. What role did you have during the majority of your nursing career; i.e., med/surg, home health, psych?

_______________________________________________________________________________________________

List all of the states in which you have been licensed as an RN and indicate the current status:

NA

1. ___________________ Active 2. ___________________ Active 3. ___________________ Active

Inactive Inactive Inactive

4. ____________________ Active 5. ____________________ Active 6. ____________________ Active

Inactive Inactive Inactive

Clinical Requirement

1. I understand it is my responsibility to arrange for and receive a verbal commitment from a clinical site prior to

enrollment. I will include below the full name and address of the health care facility I have made arrangements with, along with the site representative's name and his/her contact information.

Yes

NA ? completing theory only

2. In preparation for clinical, I acknowledge that Castle Branch will be my document manager.

Yes

NA ? completing theory only

My clinical experience will be arranged at: _____________________________________________________________

Address: ________________________________________________________________________________________

City: ____________________________________________________ State: ______________ Zip: ________________

Contact name: ____________________________________________ His/her job title: _________________________

Email address: ____________________________________________ Phone: _________________________________

Legal Questions

If you respond Yes to any of the below questions, please provide a complete description of the circumstances with dates in the space provided below. You will also be requested to submit copies of all communication from the citing agency, including evidence of completion / compliance with court and/or Board of Nursing requirements.

A. Have you ever been convicted, pled guilty or no contest/nolo contendere, pled guilty to or been granted a

deferred judgment or sentence for a felony, misdemeanor, or other criminal offense excluding minor traffic

violations?

Yes

No

B. Is there any pending criminal prosecution against you which would constitute a felony?

Yes

No

C. Are you currently being investigated or is disciplinary action pending against any professional license(s) or

certificate(s) held by you?

Yes

No

D. Has any nursing license or certificate ever held by you in any state or country been denied, revoked, suspended,

stipulated, placed on probation, or otherwise subjected to any type of disciplinary action?

Yes

No

E. Have you ever been treated for abuse or misuse of any alcohol or chemical substance?

Yes

No

F. Have you ever experienced a physical, emotional, or mental condition that has endangered the health or safety

of persons entrusted in your care?

Yes

No

Additional Information:

Acknowledgment

If you respond No to any of the following statements, contact the Continuing Nursing Education office to review the

requirement and your requested enrollment.

A. I have contacted the state board of nursing in which I wish to renew/endorse my license to confirm what

requirements are needed for my situation?

Yes

No

B. I have reviewed the RN Refresher Course Program Overview located at sdstate.edu/nursing/refresher-

course-rn.

Yes

No

C. I have opened an account with Castle Branch in my legal first and last name as recorded on page one of this

application, and I have requested the two background searches required for enrollment. I understand my

enrollment for application may be received, but not accepted until the results of both background searches are

accessible via my Castle Branch account by the Continuing Nursing Education office.

Yes

NA ? completing theory only

D. I have emailed verification of my past or present nursing license to

SDSU.ContinuingNursingEducation@sdstate.edu. Verification is available free of charge at ,

when selecting the Quick Confirm option, then downloading the report. If your state does not participate in

, you may obtain verification from each state Board of Nursing in which you were/are currently

licensed.

Yes

No

E. I understand that if I am convicted, plead guilty or no contest, or receive a suspended imposition of sentence for

a felony or other criminal offense (excluding minor traffic violations) while enrolled in the Independent Study

Refresher Course, I will report the offense within two days to the Continuing Nursing Education office in the

College of Nursing.

Yes

No

I hereby verify that all the information contained in this document is accurate and truthful to the best of my

knowledge:

Signature ______________________________________________________________ Date _____________________

To Complete Your Application:

Email a copy of your license verification from the report to the Continuing Nursing Education office SDSU.ContinuingNursingEducation@sdstate.edu.

Email any additional documentation as required of you through the application to the Continuing Nursing Education office.

Program Enrollment

Your enrollment application will be reviewed after both required background searches are available through Castle Branch. At this time, you will be notified via email of the status of your enrollment request.

After acceptance into the program, the course tuition of $1500.00 must be submitted to South Dakota State University. You will be contacted via email with instructions for payment submission.

Once enrolled, you will receive a packet of information by USPS with instructions on how to log into the website and other information you will need prior to clinical.

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