Escolar Documentos
Profissional Documentos
Cultura Documentos
FEB 21 1995
01-03632
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To be completely consistent with the ADA, we would recommend that
Question 5 be revised to read as follows:
Sincerely,
Sheila M. Foran
Attorney
Public Access Section
Enclosure
01-03634
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SAMPLE QUESTIONS
-5-
c. academic misconduct, including such acts as cheating;
d. misconduct involving student activities;
e. theft;
f. excessive absences;
g. failure to complete assignments in a timely manner;
h. actions in disregard of the health, safety and welfare
of others;
i. sexual harassment;
j. neglect of financial responsibilities.
"Currently" does not mean on the day of, or even the weeks
or months preceding the completion of this application. Rather,
it means recently enough so that the condition or impairment may
have an ongoing impact.3
01-03636
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Q. In the past year, have you illegally used drugs? If
yes, provide details. (Illegal use of drugs means the unlawful
use of one or more drugs and/or the unlawful possession or
distribution of drugs. It does not include the use of drugs
taken under supervision of a licensed health care professional,
or other uses authorized by federal law provisions.)
21 November 1994
Sincerely,
John H. Chase
General Counsel
Enclosure
01-03638
STATE OF VERMONT
RENEWAL APPLICATION
* The fee of $40.00 represents the renewal fee of $35.00 and a $5.00
assessment
in accordance with 3 V.S.A. S 124 (b)
Please check (X) if you wish inactive status (no fee required):
INFORMATION NEEDED
Circle yes or no, a yes requires an explanation * during the previous 2 years,
have you:
1. Applied for and been denied a nursing license in another state, or had a
nursing license suspended? Yes or No
2. Been subject to a disciplinary proceedings before a state board of
nursing? Yes or No
3. Been convicted of a criminal offense, other than minor traffic violations?
Yes or No
4. Had a problem with substance abuse? Yes or No
5. Received care for a physical or mental health problem that may cause a
threat to public safety during nursing practice? Yes or No
* If necessary, additional pages may be attached.
at
(Name of specific Agency/Institution) (City/State) (Position)
OR
B. I have completed a Board approved program for re-entry into nursing within
the past five years
at
(Program Sponsor (School, Institution, or Person) (City/State) (Date)
** If private duty position - please note name, address of each patient(s),
number of days and hours for each; diagnosis; nursing care provided;
physician's
name and address. Attach additional papers if needed.
YOU MUST COMPLETE AND SIGN THE REVERSE SIDE OR YOUR
LICENSE WILL NOT BE
RENEWED
Section III
3) Do you now hold or have you ever held a Nursing License that has been
subject to disciplinary proceedings before any state licensing authority
or had a license revoked or limited in any way? Yes No
4) Have you ever been convicted of a criminal offense, other than a minor
traffic violation? Yes No
Section IV
STATEMENT OF APPLICANT
APPLICANT:
01-03640