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NURSING PERSONNEL Send your completed list in an electronic format No mailed or faxed copies please Nevada State Board of Nursing 5011 Meadowood Mall Way Suite 300 Reno NV 89502-6576 nursingboard nsbn.state. 125 requires that you submit a list of nursing personnel to this office three times yearly as directed by the Nevada State Board of Nursing. Please list separately and in alphabetical order - Registered Nurses Licensed Practical Nurses Nursing Assistants Nursing Assistant Trainees. Please use a separate form for each agency/facility. Address STREET/PO BOX CITY Nursing administrator responsible for accuracy of information STATE ZIP Telephone PRINT AREA CODE I affirm/swear that this facility/agency has verified the status of all licensed and/or certified nursing personnel listed on the attached forms directly with the Nevada State Board of Nursing via the Board s website www. Personnel lists are subject to random audit by the Board. Evidence that the status was not verified may indicate a violation of the Nurse Practice Act and will be subject to further investigation. Signature of nursing administrator Date Title USE APPROPRIATE COLUMNS LAST name/FIRST name Permanent Nevada License/Certificate No. Temporary Nevada Nevada Interim Permit No. Expiration Date NEVADA STATE BOARD OF NURSING - NURSING PERSONNEL. nv*us DATE DUE February 24 2014 FOR PERIOD OF October November and December 2013 The Nurse Practice Act NRS 632. Computer printouts of this form are acceptable or may be reproduced as needed but they must be accompanied by the signed attestation of the nursing administrator. By signing this form you are attesting that your agency/facility has verified the licensure and/or certification status of the nursing personnel at your facility. The nursing administrator must be a nurse licensed in Nevada* Agency/Facility Please indicate if this is a new agency/facility name. nevadanursingboard. org or by telephone and that all nursing personnel on this list hold active or active/restricted licenses and/or certificates. Computer printouts of this form are acceptable or may be reproduced as needed but they must be accompanied by the signed attestation of the nursing administrator. By signing this form you are attesting that your agency/facility has verified the licensure and/or certification status of the nursing personnel at your facility. By signing this form you are attesting that your agency/facility has verified the licensure and/or certification status of the nursing personnel at your facility. The nursing administrator must be a nurse licensed in Nevada* Agency/Facility Please indicate if this is a new agency/facility name. Computer printouts of this form are acceptable or may be reproduced as needed but they must be accompanied by the signed attestation of the nursing administrator. By signing this form you are attesting that your agency/facility has verified the licensure and/or certification status of the nursing personnel at your facility. The nursing administrator must be a nurse licensed in Nevada* Agency/Facility Please indicate if this is a new agency/facility name.

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