Application # 283612
Submitted on: 08-Nov-2024
Kentucky Board of Nursing312 Whittington Parkway, Suite 300 Louisville, KY 40222 (502) 4293300 kbn.ky.gov
Dialysis Technician Credential – Initial
Before submitting your application be advised that ALL FEES ARE NON-REFUNDABLE.
Please review the following application requirements and additional information:
 Complete the application and submit the fee of $70.
o Applications are valid for one year.

If requirements are not met within one year, your application will expire, and
you will have to the start process over again.
o Applying for initial DT Credential and you have completed a DT Training Program
in Kentucky and the Clinical Internship, or
o Applying for initial DT Credential and you have completed an out of state DT
Training Program and you do not hold national DT certification.

Additionally, your DT Training Program curriculum has been reviewed and
approved by KBN staff and you have completed the Clinical Internship.
 Complete the state and federal criminal background check through IdentoGO®.
o
Complete the state and federal criminal background check through IdentoGO®
 Complete and submit Checklist for Dialysis Technician Competency Validation
o
This form is completed by your immediate supervisor, signed and submitted with
your application for Dialysis Technician Credentialing.
 Submit proof of certification from one of the following organizations:
o The Board of Nephrology Examiners Nursing Technology (BONENT);
o The Nephrology Nursing Certification Commission (NNCC); or
o The National Association of NephrologyTechnicians/Technologists (NANT).
 Complete the KBN Out-of-State DT Training Module and Quiz.
o The module and quiz will be sent by email upon application review.
 You may return the completed quiz to:
 Email to kbnweb.dtmain@ky.gov
 Upload to the KBN Nurse Portal Message Center
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Application # 283612
Submitted on: 08-Nov-2024
o Send to the category DT
Mail
to the KBN at the address listed on the form


Sign and Submit the KBN DT Attestation Form to:
o
Email to kbnweb.dtmain@ky.gov

Upload to the KBN Nurse Portal Message Center
 Send to the category DT
Mail to the KBN at the address listed on the form
License Application Type
In accordance with 201 KAR 20:476 submit this completed application form and appended materials to the Kentucky
Board of Nursing, DT Program prior to the expiration date of the credential.
License Type:
DT Credential
Application Type:
Dialysis Technician Credential - Initial
General Information
Please verify the name that is listed on this application. Your legal name should be as it appears on a current,
government-issued identification such as a driver license or passport.
If your name is different than what is currently displayed, please contact KBN to provide the legal name change
document to update.
If you have an address change, you will need to submit through the Manage Profile link on the upper left corner of your
Nurse Portal Dashboard located in the box above the message center.
Demographic Information
Salutation:
Full Legal Name Required:
AUTUMN MARIE ACUFF
Maiden Name:
Identifying information
What is your Gender?:
Female
What is your Race? (Please select ALL that
apply):
White/Caucasian
Are you of Hispanic or Latino origin?
No
Contact Information
Residential Address
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Application # 283612
Submitted on: 08-Nov-2024
(Also Mailing Address)
4190 Apple Grove Court
Independence KY 41051
UNITED STATES
Phone Number(s)
Cell:
(513) 287-9119 (Primary Phone)
Education History
If you have previously submitted an application for any license type with KBN, the education that was reported at the
time may be shown on this page.
Click on “+Add” to enter the education you are using for the basis of this licensure application.
Education
Program Type:
Dialysis Tech (DT)
Program Name:
DAVITA KY OHIO HEMODIALYSIS
Program Address:
400 Centerview Blvd Crestview Hills KY 41017
Education Status:
Expecting Graduation
Expected graduation date:
11/09/2024
Please indicate the Education program you are
using as the basis for licensure:
Davita KY Ohio Hemodialysis - Crestview Hills
(Inactive)
Employment History
List your current employment information as a Dialysis Technician.
Eligibility Questions
If you answer "YES" to any of these questions, you SHALL provide the following documents:



A detailed letter of explanation for each action taken.
A certified copy of the Board’s or other licensing agency’s action
Please list the event(s) and include state and year received.
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Application # 283612
Submitted on: 08-Nov-2024
1 Has any licensing or regulatory authority in any state(s) / jurisdiction(s), other than KBN, EVER denied, limited suspended,
probated, revoked, or otherwise disciplined your nursing or other professional license/certification or your privilege to practice?
Response: No
Available response options:
'Yes', 'No'
2 Do you have a current investigation pending on your nursing license, other professional license/certification or your privilege to
practice in any state(s)/jurisdiction(s) other than with KBN?
Response: No
Available response options:
'Yes', 'No'
3 Have you EVER been convicted of a felony? You shall report ALL felony convictions* and provide certified court records and a
detailed letter of explanation.
*Per KRS 314.011 (21) Convictions include conditional discharge, a guilty plea pursuant to pretrial diversion, pleading no contest,
nolo contendre or entered an Alford plea. Please list the event(s) and include state and year received. You may be asked for additional
documentation to be submitted to KBN.
Response: No
Available response options:
'Yes', 'No'
4 Have you EVER been convicted of a misdemeanor including DUI's? You shall report ALL misdemeanor convictions* and provide
certified court records and a detailed letter of explanation.
*If the conviction* (including DUI's) is less than five years old, you shall provide certified court records and a detailed letter of
explanation.
* If the conviction * (including DUI's) is more than five years old, no additional documentation is required unless requested by KBN.
*Per KRS 314.011 (21) Convictions include conditional discharge, a guilty plea pursuant to pretrial diversion, pleading no contest,
nolo contendre or entered an Alford plea. Please list the event(s) and include state and year received. You may be asked for additional
documentation to be submitted to KBN.
Response: No
Available response options:
'Yes', 'No'
5 Are you currently a participant in a state board/designee monitoring program including alternative to discipline, diversion or a peer
assistance program other with than KBN?
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Application # 283612
Submitted on: 08-Nov-2024
Response: No
Available response options:
'Yes', 'No'
I certify that I am the person referred to in this application; that I have read and understand
administrative regulations 201 KAR 20:472, 201 KAR 20:474; 201 KAR 20:476; and 201
KAR 20:478 and 902 KAR 20:018, 907 KAR 1:400, and 42 CFR 405.2102; that all statements
contained herein and on all attachments are true and correct In every respect and that I have
read and understand this application and all requirements stated therein. I understand that
failure to comply with requirements for credential may subject this application to denial status.
I understand that all information on this application is subject to an audit for verification and
that knowingly supplying false information on or with this application is a violation of KRS
Chapter 314 and may subject me to the full range of disciplinary action described therein.
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Application # 283612
Submitted on: 08-Nov-2024
Name: AUTUMN ACUFF
Payment confirmation code: 118184668
ORBS Transaction Reference: cee58f8a909e4178b45b6f47d194c478
Payment Date and Time:
11/8/2024 9:07:41 AM
Application Fee Amount:
DIALYSIS TECHNICIANS INITIAL APPLICATION $70.00
Total:
$70.00
NOTE: This document is a copy of the electronic license application for the person named
above and does NOT constitute a verification of their license or represent a copy of the
individual’s license.
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