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KBN Forms & Publications

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FORMS

PUBLICATIONS/BROCHURES

Forms

CERTIFICATE OF LICENSURE (SUITABLE FOR FRAMING)

Certificate of Licensure/Registration Order Form [PDF Format - 32KB]

CONTINUING COMPETENCY/CE

Application for Initial Provider Approval [PDF Format - 128KB]
Application for Renewal of Providership [PDF Format - 137KB]
Individual Request for Review of CE Activities [PDF Format - 71KB]
CE Brochure [PDF Format - 60KB]
CE Provider List [PDF Format - 94KB]
Guidelines for CE Providers [PDF Format - 325KB]
Internet CE Providers [PDF Format - 8KB]
Preceptorship Validation Form [PDF Format - 32KB]
Providers for Domestic Violence CE [PDF Format - 19KB]
Providers for HIV/AIDS CE [PDF Format - 32KB]
Providers for IV Therapy CE [PDF Format - 16KB]
Providers for Pharmacology CE [PDF Format - 11KB]
Providers for SANE CE [PDF Format - 4KB]
Refresher Courses [PDF Format - 2KB]
Refresher Courses from Nursing Boards Other Than Kentucky [PDF Format - 57KB]

CREDENTIALS/LICENSURE
For your convenience, application forms are provided below for specific licensure methods. These forms include the instructions and attachments.

Application Forms

SANE Credential Application Form [PDF Format - 97KB]

Application Request Forms*
*The applications in this section require an additional fee when the application is submitted via paper. There is no additional fee if these forms are submitted electronically. Please fill out and submit the request form along with the additional fee, or visit the Online Services page if you wish to submit electronically.

Paper Application Request Form - RN & APRN or APRN Only Licensure [PDF Format - 52KB]

Paper Application Request Form - Examination [PDF Format - 94KB]

Paper Application Request Form - Endorsement [PDF Format - 94KB]

Paper Application Request Form - Reinstatement [PDF Format - 93KB]

Paper Application Request Form - Retired Status [PDF Format - 94KB]

Paper Application Request Form - Licensure Renewal [PDF Format - 86KB]
If you wish to renew using a paper application, you must send in this request form by October 15.

Other Licensure Forms

Licensed Nurse Address/Email Change Form [PDF Format - 87KB]
Criminal Background Request Form (CourtNet) [PDF Format - 13KB]
KBN Notification of CAPA-CS [PDF Format - 100KB]
Change of Practice Address for APRN with a CAPA-CS [PDF Format - 29KB]
Licensed Nurse Name Change Form [PDF Format - 89KB]
NCLEX Special Accommodations Request Form [PDF Format - 27KB]
NurSys Licensure Verification
Rescission Letter for Collaborative Agreement for APRN Prescriptive Authority for Controlled Substances (CAPA-CS) Form [PDF Format - 7KB]
Verification of Employment - Outside of Kentucky (Attachment 1) [PDF Format - 93KB]
Verification of Original Licensure (Attachment 2) [PDF Format - 95KB]
Verification of Licensure to an Entity Other than a Board of Nursing Request Form [PDF Format - 19KB]

DATA ROSTER DOWNLOAD

RN/LPN/APRN Data Roster Download
- Layout for RN/LPN Database Roster [PDF Format - 48KB]
- Layout for APRN Database Roster [PDF Format - 78KB]
KNAR Data Roster Request Form [PDF Format - 27KB]
- Layout for KNAR Database Roster [PDF Format - 10KB]
SANE Data Roster Request Form [PDF Format - 27KB]
- Layout for SANE Database Roster [PDF Format - 9KB]
Instructions for Importing Text Files Into Microsoft Excel [PDF Format - 117KB]

DIALYSIS TECHNICIAN CREDENTIALING

DT Address Change Form [PDF Format - 53KB]
DT Application for Credential [PDF Format - 29KB]
DT Application for Training Program Approval [PDF Format - 19KB]
DT Checklist for Competency Validation [PDF Format - 18KB]
DT General Information & Checklist [PDF Format - 26KB]
DT List of Training Programs [PDF Format - 10KB]
DT List of Training Program Graduates [PDF Format - 14KB]
DT Reissue Form (used for name change or request for duplicate credential) [PDF Format - 15KB]
DT Training Program Guide [PDF Format - 35KB]

EDUCATION

Clinical Instructor Record Form [PDF Format - 47KB]
Nurse Faculty Record Form [PDF Format - 49KB]

FEE SCHEDULE

Fees for Licensure Applications and Services [PDF Format - 26KB]

INVESTIGATION & DISCIPLINE

Consumer Complaint Form [PDF Format - 33KB]
Criminal Convictions Brochure [PDF Format - 28KB]
Facility Complaint Form [PDF Format - 34KB]
Kentucky Alternative Recovery Effort (KARE) for Nurses Brochure [PDF Format - 60KB]
List of Evaluators by City [PDF Format - 49KB]
Nursing Licensure: Disciplinary Process and Procedures Brochure [PDF Format - 139KB]
State and Territorial Boards of Nursing: What Every Nurse Needs to Know (published by the National Council of State Boards of Nursing) [PDF Format - 617KB]
Your State Board of Nursing Works for You: A Health Care Consumer's Guide (published by the National Council of State Boards of Nursing) [PDF Format - 769KB]

KARE (COMPLIANCE)

Academic Performance Evaluation Form [PDF Format - 43KB]
Academic Verification Form [PDF Format - 40KB]
Components of Mental Health and/or Chemical Dependency Evaluations [PDF Format - 30KB]
Counselor Evaluation Form [PDF Format - 46KB]
Counselor/Therapist Verification Form [PDF Format - 40KB]
KARE Program - Employer Verification Form [PDF Format - 41KB]
List of Evaluators by City [PDF Format - 49KB]
Meeting Documentation Form [PDF Format - 22KB]
Monitoring Schedule [PDF Format - 36KB]
Monthly Self Report [PDF Format - 53KB]
Prescription Medication Report [PDF Format - 46KB]
Probation/Parole Report [PDF Format - 40KB]
Probation/Parole/Drug Court Verification Form [PDF Format - 39KB]
Relapse Prevention Plan [PDF Format - 48KB]
Treating Practitioner Verification Form [PDF Format - 40KB]
Waiver of Confidentiality [PDF Format - 30KB]
Work Performance Evaluation Form [PDF Format - 51KB]

Note: The Compliance forms provided above are used ONLY for the KARE for Nurses Program.

NURSE AIDE REGISTRY (KNAR)

Nurse Aide Name/Address Change Form [PDF Format - 47KB]

NURSING INCENTIVE SCHOLARSHIP FUND (NISF)

NISF Application Form (Includes Instructions) [PDF Format 31KB]

PRACTICE (see also: Practice Opinion Summaries)

Assuring Safe Nursing Care in Kentucky Brochure [PDF Format - 69KB]
Request for Advisory Opinion Form [PDF Format - 10KB]

SANE CREDENTIALING

Application for SANE Credential [PDF Format - 97KB]
Sexual Assault Nurse Examiner Program Brochure [PDF Format - 23KB]
SANE Training Dates and Registration Information [PDF Format - 874KB]

Publications/Brochures

Kentucky Alternative Recovery Effort (KARE) for Nurses Brochure

ANNUAL REPORTS

KBN Annual Reports

BROCHURES

Assuring Safe Nursing Care in Kentucky Brochure [PDF Format - 69KB]
LPN Scope of Practice in Kentucky [PDF Format - 274k]
CE Brochure [PDF Format - 60KB]
Criminal Convictions Brochure [PDF Format - 28KB]
KARE Participant Handbook [PDF Format - 99KB]
Kentucky Alternative Recovery Effort (KARE) for Nurses Brochure [PDF Format - 60KB]
Nurse Licensure Compact Brochure [PDF Format - 60KB]
Nursing Licensure: Disciplinary Process and Procedures [PDF Format - 139KB]
Sexual Assault Nurse Examiner Program [PDF Format - 23KB]

NEWSLETTERS (KBN CONNECTION)

KBN Connection - Spring 2013
e-Pub version | PDF: pages 1-16 [2.2MB] | PDF: pages 17-32 [1.6MB]
KBN Connection - Winter 2012
e-Pub version | PDF: pages 1-16 [2.5MB] | PDF: pages 17-32 [1.92MB]
KBN Connection - Fall 2012
e-Pub version | PDF: pages 1-16 [2.7MB] | PDF: pages 17-32 [2.48MB]
KBN Connection - Summer 2012
e-Pub version | PDF: pages 1-16 [2.5MB] | PDF: pages 17-32 [2.24MB]
KBN Connection - Spring 2012
e-Pub version | PDF: pages 1-16 [3.4MB] | PDF: pages 17-32 [5MB]
KBN Connection - Winter 2011
e-Pub version | PDF: pages 1-16 [2.1MB] | PDF: pages 17-32 [1.6MB]
KBN Connection - Fall 2011
e-Pub version | PDF: pages 1-16 [3.2MB] | PDF: pages 17-32 [1.0MB]
KBN Connection - Summer 2011
e-Pub version | PDF: pages 1-16 [3.7MB] | PDF: pages 17-32 [1.5MB]
KBN Connection - Spring 2011
e-Pub version | PDF: pages 1-16 [2.4MB] | PDF: pages 17-32 [2.3MB]
KBNursing Connection - Winter 2010
e-Pub version | PDF: pages 1-16 [3.5MB] | PDF: pages 17-32 [2.6MB]
KBNursing Connection - Fall 2010
e-Pub version | PDF: pages 1-16 [3.7MB] | PDF: pages 17-32 [2.4MB]
KBNursing Connection - Summer 2010
e-Pub version | PDF: pages 1-16 [2.1MB] | PDF: pages 17-32 [2.5MB]
KBNursing Connection - Spring 2010
e-Pub version | PDF: pages 1-16 [2.5MB] | PDF: pages 17-32 [2.4MB]
KBNursing Connection - Winter 2009-2010
e-Pub version | PDF version [3.4MB]
KBNursing Connection - Fall 2009 [PDF Format - 3.8MB]
KBNursing Connection - Summer 2009 [PDF Format - 3.4MB]
KBNursing Connection - Spring 2009 [PDF Format - 3.7MB]
KBNursing Connection - Winter 2008-09 [PDF Format - 3.5MB]
KBNursing Connection - Fall 2008 [PDF Format - 1.7MB]
KBNursing Connection - Summer 2008 [PDF Format - 3.5MB]
KBNursing Connection - Spring 2008 [PDF Format - 3MB]
KBNursing Connection - Winter 2007-08 [PDF Format - 1.4MB]
KBNursing Connection - Fall 2007 [PDF Format - 2.3MB]
KBNursing Connection - Summer 2007 [PDF Format - 3MB]
KBNursing Connection - Spring 2007 [PDF Format - 2.7MB]
KBNursing Connection - Winter 2006-07 [PDF Format - 3.4MB]
KBNursing Connection - Fall 2006 [PDF Format - 2.8MB]
KBNursing Connection - Summer 2006 [PDF Format - 2.9MB]
KBNursing Connection - Spring 2006 [PDF Format - 3.2MB]

For older issues, see the Kentucky Dept. for Libraries and Archives

Articles from guest authors may be submitted for publication in the KBNursing Connection. Priority will be given to subject matter dealing with Kentucky nurses and issues affecting nursing practice in the Commonwealth. If you plan to submit an article, please review the Guidelines for Submission of Guest Articles [PDF Format - 20KB]. Submit articles to the editor at ericw.velazquez@ky.gov.

If you are interested in advertising in the KBNursing Connection, contact Michele Forinash, Publishing Concepts, Inc., at 1-800-561-4686 or 501-221-9986, or by email at mforinash@pcipublishing.com.

If you are retiring from active status and would like to continue receiving the Board's quarterly magazine, let us know using the KBN Magazine Mailing List Opt-In form.

NURSE LICENSURE COMPACT (NLC)

Nurse Licensure Compact Brochure [PDF Format - 60KB]

PRACTICE OPINION SUMMARIES

Practice Opinion Summaries
Advisory Opinion Statements (AOS)
AOS Summary Reports (listed under each year)
AOS Consolidated Summary 1983-2010 [PDF Format - 89KB]

STATISTICS

Go to the Licensure Statistic Reports page for aggregated data on licensees.

Last Updated 4/18/2013

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