Form RS-05 8 10/5/23; 2/22/24; 7/12/24
4. Criminal Charges, Disciplinary Action, or Judicial Declaration of Mental
Incompetence: If you answer “yes” to the criminal charge, discipline, or competency
questions on the application, you must write a statement in the available space on the
application form, describing the date, location and circumstances of the incident,
and the resulting action taken by the court or disciplinary board. If you have more
than one incident you are reporting, you must speak to every case/charge that has been
filed. In addition, you will be required to upload certified copies of identified documents.
(A) Have you ever had disciplinary action taken against a nursing license, recognition,
certificate, or privilege to practice; any professional or occupational license, recognition,
or certificate; and/or any application for a nursing or professional or occupational license,
recognition, or certificate in any state, territory or country not previously reported in
writing to the Oklahoma Board of Nursing?”
a. If you answered “yes”, you must type in the space available a statement
describing the date, location, and circumstances of the incident(s), and, if
applicable, the resulting action(s) taken by the disciplinary board.
b. If you are reporting more than one incident, you must describe every case that
has been filed.
c. You will need to upload certified copies of the charges/complaints, findings of
fact, and orders from the licensing agency.
(B) Is there currently any investigation of your nursing license, recognition, certificate, or
privilege to practice; and/or any professional or occupational license, recognition, or
certificate; and/or any application for a nursing and/or professional or occupational
license, recognition, or certificate in any state, territory or country not previously reported
in writing to the Oklahoma Board of Nursing?
a. If you answered “yes”, you must type in the space available a statement
describing the date, location, and circumstances of the incident(s), and, if
applicable, the resulting action(s) taken by the disciplinary board.
b. If you are reporting more than one incident, you must describe every case that
has been filed.
(C) Have you been charged and/or convicted in any criminal offense not previously
reported in writing to the Oklahoma Board of Nursing, including those pending appeal?
(You may exclude minor traffic violations, but must report all DUI/DWI charges and/or
DUI/DWI convictions)
Check all that apply:
[ ] been convicted of a misdemeanor?
[ ] been convicted of a felony?
[ ] pled nolo contendre, no contest, or guilty?
[ ] received deferred adjudication, to include but not limited to deferred
prosecution agreement?
[ ] been placed on community supervision or court-ordered probation, whether or
not adjudicated guilt?
[ ] been sentenced to serve jail or prison time? Court-ordered confinement?
[ ] been granted pre-trial diversion, to include but not limited to Drug Court?
[ ] have any pending criminal charges?
[ ] have any pending violation of the law?