II.
NORTHWESTERN OKLAHOMA STATE UNIVERSITY
Bachelor of Science in Nursing (BSN) Program
APPLICATION for NURSING PROGRAM
Please print or type all information.
Please indicate below that you are applying for the Generic track completion and
the campus you will be attending. The Generic Track includes students who
progress through the 4 year BSN program who do not have an associate degree
or diploma in nursing, including LPN students.

____Which campus do you prefer? (circle one)
Alva
Enid
WW
Ponca City
Date _______________ NWOSU Student ID #: _________________________
Legal Name______________________________________________________
Last
First
Middle
Maiden
Current Address
________________________________________________________________
Street Name and Number
________________________________________________________________
City
County
State
Home Telephone_____________________
Area Code
Number
Zip
Cell Phone__________________
Area Code
Number
E-Mail Address

Have you ever been arrested, charged, and/or convicted of a felony?
Yes or No (Please circle one)
Academic year 16-17
7
Formal education after high school (start with earliest school to present)
Date
From
Date
To
School
Credit
Hours
Location: City &
State
Degree
Major
If one of the above programs was not completed, state the reason
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
High School name and year graduated _________________________________
High School Address______________________ Phone Number____________
High School City & State___________________
High School GPA ________________________
(Attach copy of high school transcript)
Date of GED (if applicable) ____________________________
(Attach official GED certificate)
Location GED taken _______________________
Have you been admitted to NWOSU?
Yes
or
No
TOEFL Score (if applicable)___________(Attach official documentation of score)
Academic year 16-17
8
Courses Currently Enrolled in at the present time and the college/university
where completing.
_____________________________________________________________
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Additional Courses to be completed: (indicate when these will be taken and the
college/university)
_____________________________________________________________
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PARTICIPATION
Organizations (Indicate offices held)
_____________________________________________________________
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Interests, activities:
_____________________________________________________________
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Volunteer work
_____________________________________________________________
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Leadership activities
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Academic year 16-17
9
EMPLOYMENT
(Start with most recent)
Date
From
To
Employer
Address
Type
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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NURSING EDUCATION HISTORY
If you have attended another school of nursing, give the following information:
School____________________________________
City, State & Zip____________________________
Date of entrance____________________________
Date of leaving _____________________________
Graduation Year____________________________
Reason for
leaving___________________________________________________________
Have you submitted an application to the NWOSU Division of Nursing
previously?_________ Date__________
Comments:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Academic year 16-17
10
Licensure:
CNA license number _______________________
State issued __________________________
Name of Program___________________
Exam Score__________________________
If LPN (LVN) permanent license number ______________________
State issued__________________
Name of Program_____________________
ADDITIONAL INFORMATION
Is there any additional information you feel pertinent to your consideration for
admission? If yes, give explanation:
Academic year 16-17
11
I, _______________________________________________, herein make
application for admission into the Nursing Program at Northwestern Oklahoma
State University.
Summer Semester for Generic Track
I understand that the Nursing Program of Northwestern Oklahoma State University
admits a limited number of students due to available resources. Although, I may
meet or exceed the minimum requirements for admission, circumstances may
prevent the NWOSU Nursing Program from admitting all students who meet the
admission criteria.
_______________________________________
Signature
______________
Date
Falsifying any records pertinent to this application can lead to ineligibility or
immediate dismissal from the nursing program.
______________________________________
Signature
Academic year 16-17
_________________
Date
12
V.
Northwestern Oklahoma State University
Division of Nursing
Reference Form #1
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE APPLICANT:
Name of applicant_________________________________________ ________
Last Name
Date________________________
First Name
Middle Name
Maiden Name
Phone Number (____)_____________
The Family Educational Rights and Privacy Act of 1974 and its amendments
guarantee students access to their individual records. Students may waive their
right of access to Reference Forms. The choice of the applicant is indicated
below. Failure to sign will deny student access to Reference Forms.
______ I do waive (give up) the right to review this information. (Applicant does
not have access to this information on this form)
______ I do not waive (give up) the right to review this information. (Applicant
may have access to information)
Signature_____________________________ Date_______________________
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE PERSON SERVING AS A
REFERENCE:
When completed return form to:
Division of Nursing
Northwestern Oklahoma State University
709 Oklahoma Blvd.
Alva, OK 73717-2799
The above applicant is a candidate for admission to the NWOSU Nursing
Program. This reference form will become a part of the student's permanent file.
According to the policy of the NWOSU Nursing Program, the above applicant has
access to their personal file upon written request to the Chair of the Nursing
Program unless they waive their right to access as indicated above. Your
cooperation in completing and promptly returning this form will assist both the
applicant and the Nursing Program.
1. How long have you known the applicant and in what capacity?__________
________________________________________________________________
________________________________________________________________
____
________
2. What do you consider the strengths or weaknesses of the applicant? If
possible, give examples. _____________
_______________________
______________
_____
_
_______________________________________________________________
________________________________________________________________
Academic year 16-17
13
3. Do you place full confidence in the applicant's integrity?_____
______
Please explain____________________________________________________
_____________________________________________________ __________
___________________________________________________________
4. In what activities has the applicant taken an active part? _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. What experiences has the applicant had that might have influenced the
applicant’s interest in nursing?____________ _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
6. Does the applicant interact positively with people?______
________________________________________________________________
7. What experiences has the applicant had that support your answer?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Rate the applicant on a 5 - 1scale according to the following criteria,
with 5 as high and 1 as low.
Superior Above Average
Average
Below
Poor
Average
Dependability
5
4
3
2
1
Work Performance
5
4
3
2
1
Appearance
5
4
3
2
1
Character Traits
5
4
3
2
1
Stability, Honesty
5
4
3
2
1
Initiative, Creativity
5
4
3
2
1
General Impression
5
4
3
2
1
Academic year 16-17
14
Additional Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date:
Signature:
Printed Name:
Position:
Address:
Phone Number:
Thank you for taking time to complete a Reference Form for an NWOSU Division
of Nursing applicant. Your contributions are appreciated.
Academic year 16-17
15
V.
Northwestern Oklahoma State University
Division of Nursing
Reference Form #2
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE APPLICANT:
Name of applicant_________________________________________ ________
Last Name
Date________________________
First Name
Middle Name
Maiden Name
Phone Number (____)_____________
The Family Educational Rights and Privacy Act of 1974 and its amendments
guarantee students access to their individual records. Students may waive their
right of access to Reference Forms. The choice of the applicant is indicated
below. Failure to sign will deny student access to Reference Forms.
______ I do waive (give up) the right to review this information. (Applicant does
not have access to this information on this form)
______ I do not waive (give up) the right to review this information. (Applicant
may have access to information)
Signature_____________________________ Date_______________________
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE PERSON SERVING AS A
REFERENCE:
When completed return form to:
Division of Nursing
Northwestern Oklahoma State University
709 Oklahoma Blvd.
Alva, OK 73717-2799
The above applicant is a candidate for admission to the NWOSU Nursing
Program. This reference form will become a part of the student's permanent file.
According to the policy of the NWOSU Nursing Program, the above applicant has
access to their personal file upon written request to the Chair of the Nursing
Program unless they waive their right to access as indicated above. Your
cooperation in completing and promptly returning this form will assist both the
applicant and the Nursing Program.
1. How long have you known the applicant and in what capacity?__________
________________________________________________________________
________________________________________________________________
____
________
2. What do you consider the strengths or weaknesses of the applicant? If
possible, give examples. _____________
_______________________
______________
_____
_
_______________________________________________________________
________________________________________________________________
Academic year 16-17
16
3. Do you place full confidence in the applicant's integrity?_____
______
Please explain____________________________________________________
_____________________________________________________ __________
___________________________________________________________
4. In what activities has the applicant taken an active part? _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. What experiences has the applicant had that might have influenced the
applicant’s interest in nursing?____________ _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
6. Does the applicant interact positively with people?______
________________________________________________________________
7. What experiences has the applicant had that support your answer?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Rate the applicant on a 5 - 1scale according to the following criteria,
with 5 as high and 1 as low.
Superior Above Average
Average
Below
Poor
Average
Dependability
5
4
3
2
1
Work Performance
5
4
3
2
1
Appearance
5
4
3
2
1
Character Traits
5
4
3
2
1
Stability, Honesty
5
4
3
2
1
Initiative, Creativity
5
4
3
2
1
General Impression
5
4
3
2
1
Academic year 16-17
17
Additional Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date:
Signature:
Printed Name:
Position:
Address:
Phone Number:
Thank you for taking time to complete a Reference Form for an NWOSU Division
of Nursing applicant. Your contributions are appreciated.
Academic year 16-17
18
V.
Northwestern Oklahoma State University
Division of Nursing
Reference Form #3
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE APPLICANT:
Name of applicant_________________________________________ ________
Last Name
Date________________________
First Name
Middle Name
Maiden Name
Phone Number (____)_____________
The Family Educational Rights and Privacy Act of 1974 and its amendments
guarantee students access to their individual records. Students may waive their
right of access to Reference Forms. The choice of the applicant is indicated
below. Failure to sign will deny student access to Reference Forms.
______ I do waive (give up) the right to review this information. (Applicant does
not have access to this information on this form)
______ I do not waive (give up) the right to review this information. (Applicant
may have access to information)
Signature_____________________________ Date_______________________
-----------------------------------------------------------------------------------------------------------THIS SECTION TO BE COMPLETED BY THE PERSON SERVING AS A
REFERENCE:
When completed return form to:
Division of Nursing
Northwestern Oklahoma State University
709 Oklahoma Blvd.
Alva, OK 73717-2799
The above applicant is a candidate for admission to the NWOSU Nursing
Program. This reference form will become a part of the student's permanent file.
According to the policy of the NWOSU Nursing Program, the above applicant has
access to their personal file upon written request to the Chair of the Nursing
Program unless they waive their right to access as indicated above. Your
cooperation in completing and promptly returning this form will assist both the
applicant and the Nursing Program.
1. How long have you known the applicant and in what capacity?__________
________________________________________________________________
________________________________________________________________
____
________
2. What do you consider the strengths or weaknesses of the applicant? If
possible, give examples. _____________
_______________________
______________
_____
_
_______________________________________________________________
________________________________________________________________
Academic year 16-17
19
3. Do you place full confidence in the applicant's integrity?_____
______
Please explain____________________________________________________
_____________________________________________________ __________
___________________________________________________________
4. In what activities has the applicant taken an active part? _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. What experiences has the applicant had that might have influenced the
applicant’s interest in nursing?____________ _________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
6. Does the applicant interact positively with people?______
________________________________________________________________
7. What experiences has the applicant had that support your answer?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Rate the applicant on a 5 - 1scale according to the following criteria,
with 5 as high and 1 as low.
Superior Above Average
Average
Below
Poor
Average
Dependability
5
4
3
2
1
Work Performance
5
4
3
2
1
Appearance
5
4
3
2
1
Character Traits
5
4
3
2
1
Stability, Honesty
5
4
3
2
1
Initiative, Creativity
5
4
3
2
1
General Impression
5
4
3
2
1
Academic year 16-17
20
Additional Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date:
Signature:
Printed Name:
Position:
Address:
Phone Number:
Thank you for taking time to complete a Reference Form for an NWOSU Division
of Nursing applicant. Your contributions are appreciated.
Academic year 16-17
21
III.
General Information Packet
(Retain pages 22 to 33 for your records)
General Information Packet Includes:
I.
General Information
II.
The Oklahoma Board of Nursing Rules and Regulations
III.
Core Performance Standards for Admission and Progression in the Nursing Program
IV.
Record of Arrest or Commitment for Mental Incompetence
V.
Guidelines for NCLEX Candidates with History of Arrests/Convictions/Prior
a. Disciplinary Action
VI.
Certified Background Check (National)
General Information
A.
B.
C.
D.
E.
F.
G.
H.
In order to be licensed as a registered nurse, an individual must be a graduate of a State
approved Nursing Program, such as NWOSU. Candidates for licensure as a registered nurse
in Oklahoma must pass the National Council Licensure Examination for Registered Nurses
(NCLEX-RN).
Travel Requirements:
Part of the Nursing Program will include living in or traveling to Alva, Enid, WW, Ponca City,
Fort Supply, Oklahoma City and /or other cities for the clinical rotations and educational
requirements for labs/clinicals. Travel expenses are the responsibility of the student. Students
frequently share housing and travel expenses.
The NWOSU Generic Nursing Program is designed for full time students.
Student’s fees will include liability insurance at the beginning of each year while in the Nursing
Program.
Drug testing is a clinical requirement at the student’s expense. An additional student charge
may be required by governing agencies. Random drug screens may occur throughout the
nursing curriculum.
A background check is required annually at the student’s expense.
The Clinical Hub fee will be included in student fees annually which allow students to attend
clinicals.
Students should keep a copy of the completed application packet for their records.
Academic year 16-17
22
Oklahoma Nursing Practice Act
§567.8 Denial, revocation or suspension of license or certification–Administrative penalties
A. The Oklahoma Board of Nursing shall have the power to take any or all of the following actions:
1. To deny, revoke or suspend any:
a. licensure to practice as a Licensed Practical Nurse,
b. licensure to practice as a Registered Nurse,
c. licensure to practice as an Advanced Practice Registered Nurse,
d. certification to practice as an Advanced Unlicensed Assistant,
e. authorization for prescriptive authority, or
f. authority to order, select, obtain and administer drugs;
2. To assess administrative penalties; and
3. To otherwise discipline applicants, licensees or Advanced Unlicensed Assistants.
B. The Board shall impose a disciplinary action against the person pursuant to the provisions of
subsection A of this section upon proof of one or more of the following items. The person:
1. Is guilty of deceit or material misrepresentation in procuring or attempting to procure:
a. a license to practice registered nursing, licensed practical nursing, or recognition to
practice advanced practice registered nursing, or
b. certification as an Advanced Unlicensed Assistant;15
2. Is guilty of a felony, or any offense reasonably related to the qualifications, functions or
duties of any licensee or Advanced Unlicensed Assistant, or any offense an essential
element of which is fraud, dishonesty, or an act of violence, or for any offense
involving moral turpitude, whether or not sentence is imposed, or any conduct resulting
in the revocation of a deferred or suspended sentence or probation imposed pursuant
to such conviction;
3. Fails to adequately care for patients or to conform to the minimum standards of acceptable
nursing or Advanced Unlicensed Assistant practice that, in the opinion of the Board,
unnecessarily exposes a patient or other person to risk of harm;
4. Is intemperate in the use of alcohol or drugs, which use the Board determines endangers or
could endanger patients;
5. Exhibits through a pattern of practice or other behavior actual or potential inability to practice
nursing with sufficient knowledge or reasonable skills and safety due to impairment
caused by illness, use of alcohol, drugs, chemicals or any other substance, or as a
result of any mental or physical condition, including deterioration through the aging
process or loss of motor skills, mental illness, or disability that results in inability to
practice with reasonable judgment, skill or safety; provided, however, the provisions of
this paragraph shall not be utilized in a manner that conflicts with the provisions of the
Americans with Disabilities Act;
Academic year 16-17
23
6. Has been adjudicated as mentally incompetent, mentally ill, chemically dependent or
dangerous to the public or has been committed by a court of competent jurisdiction,
within or without this state;
7. Is guilty of unprofessional conduct as defined in the rules of the Board;
8. Is guilty of any act that jeopardizes a patient's life, health or safety as defined in the rules of
the Board;
9. Violated a rule promulgated by the Board, an order of the Board, or a state or federal law
relating to the practice of registered, practical or advanced practice registered nursing or
advanced unlicensed assisting, or a state or federal narcotics or controlled dangerous
substance law;
10. Has had disciplinary actions taken against the individual's registered or practical nursing
license, advanced unlicensed assistive certification, or any professional or occupational
license, registration or certification in this or any state, territory or country;
11. Has defaulted from the Peer Assistance Program for any reason;
12. Fails to maintain professional boundaries with patients, as defined in the Board rules; or
13. Engages in sexual misconduct, as defined in Board rules, with a current or former patient
or key party, inside or outside the health care setting.
C. Any person who supplies the Board information in good faith shall not be liable in any way for
damages with respect to giving such information.
D. The Board may cause to be investigated all reported violations of the Oklahoma Nursing Practice
Act.
E. The Board may authorize the executive director to issue a confidential letter of concern to a
licensee when evidence does not warrant formal proceedings, but the executive director has noted
indications of possible errant conduct that could lead to serious consequences and formal action.
F. All individual proceedings before the Board shall be conducted in accordance with the
Administrative Procedures Act.16
G. At a hearing the accused shall have the right to appear either personally or by counsel, or both, to
produce witnesses and evidence on behalf of the accused, to cross-examine witnesses and to have
subpoenas issued by the designated Board staff. If the accused is found guilty of the charges the
Board may refuse to issue a renewal of license to the applicant, revoke or suspend a license, or
otherwise discipline a licensee.
H. A person whose license is revoked may not apply for reinstatement during the time period set by
the Board. The Board on its own motion may at any time reconsider its action.
I. Any person whose license is revoked or who applies for renewal of registration and who is rejected
by the Board shall have the right to appeal from such action pursuant to the Administrative
Procedures Act.
Academic year 16-17
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J.
1. Any person who has been determined by the Board to have violated any provisions of the
Oklahoma Nursing Practice Act or any rule or order issued pursuant thereto shall be
liable for an administrative penalty not to exceed Five Hundred Dollars ($500.00)
for each count for which any holder of a certificate or license has been determined to
be in violation of the Oklahoma Nursing Practice Act or any rule promulgated or
order issued pursuant thereto.
2. The amount of the penalty shall be assessed by the Board pursuant to the provisions of this
section, after notice and an opportunity for hearing is given to the accused. In
determining the amount of the penalty, the Board shall include, but not be limited to,
consideration of the nature, circumstances, and gravity of the violation and, with respect
to the person found to have committed the violation, the degree of culpability, the effect
on ability of the person to continue to practice, and any show of good faith in attempting
to achieve compliance with the provisions of the Oklahoma Nursing Practice Act.
K. The Board shall retain jurisdiction over any person issued a license, certificate or temporary
license pursuant to this act, regardless of whether the license, certificate or temporary license has
expired, lapsed or been relinquished during or after the alleged occurrence or conduct prescribed by
this act.
L. In the event disciplinary action is imposed, any person so disciplined shall be responsible for any
and all costs associated with satisfaction of the discipline imposed.
M. In the event disciplinary action is imposed in an administrative proceeding, the Board shall have
the authority to recover the monies expended by the Board in pursuing any disciplinary action,
including but not limited to costs of investigation, probation or monitoring fees, administrative costs,
witness fees, attorney fees and court costs. This authority shall be in addition to the Board’s authority
to impose discipline as set out in subsection A of this section.
N. The Executive Director shall immediately suspend the license of any person upon proof that the
person has been sentenced to a period of continuous incarceration serving a penal sentence for
commission of a misdemeanor or felony. The suspension shall remain in effect until the Board acts
upon the licensee’s written application for reinstatement of the license.
Oklahoma Nursing Practice Act, November 2013
Academic year 16-17
25
Core Performance Standards for Admission
and Progression in the Nursing Program
A candidate for the BSN degree must have abilities and skills of four varieties: assessment,
communication, motor, and behavioral. A candidate is expected to perform in an independent
manner.
1.
Assessment: A candidate must be able to collect subjective and objective client data
accurately. Examples include: listening to heart and breath sounds, visualizing color and
appearance of skin and wounds, detecting the presence of odors, and palpation of body
structures and organs.
2.
Communication: A candidate must be able to communicate effectively with clients, other
members of the health team and family members. He/she must be able to interact with clients
and other members of the health team in order to obtain information, describe patient
situations, and perceive non-verbal communication.
3.
Motor: A candidate must have adequate motor function to effectively work with nursing
problems and issues, and carry out related nursing care. Examples of nursing care include:
providing daily client hygiene care; ambulating and positioning patients; cardiopulmonary
resuscitation; and the opening and clearing of an obstructed airway. Other gross motor clinical
activities include but are not limited to: standing, sitting, lifting, bending, and stooping. Other
fine motor clinical activities include but are not limited to: writing, computer skills, manipulating
equipment, the administration of oral, subcutaneous, intramuscular and intravenous
medications, and application of pressure to stop hemorrhage. The candidate must be able to
perform the activities of daily living” (*) and be able to function in various assigned clinical
environments.
4.
Behavioral: Candidates need to be able to tolerate physically taxing work loads, including
repetitive movements and to function effectively during stressful situations. They must be
capable of adapting to an ever-changing environment, displaying flexibility appropriately
interacting with others, and learning to function in the case of uncertainty that is inherent in
clinical situations involving clients.
Applicants who are denied progression because of failure to meet the criteria may petition the faculty
for reconsideration. The applicant will explain how he/she intends to meet the criteria in view of
his/her specific circumstances and provide rationale for why certain criteria should be waived in
his/her particular case.
(*) “Activities of daily living” include functions such as caring for oneself, performing manual tasks,
walking, seeing, hearing, speaking, and learning.
Reference: Current NWOSU Division of Nursing Policy
SERVICES FOR STUDENTS WITH DISABILITIES
Any student needing academic accommodations for a physical, mental or learning disability should
contact the Coordinator of Services for Students with Disabilities, or faculty member personally, within
the first two weeks of the semester so that appropriate accommodations may be arranged. The
location for ADA assistance is the Fine Arts building room 126 on the Alva Campus and the contact is
Calleb Mosburg. The location for ADA assistance on the Enid campus is Room 102 and the contact
Academic year 16-17
26
is Candace Reim. The location for ADA assistance on the Woodward campus is the Main Office and
the contact is Dr. Deena Fisher. The location for ADA assistance for students attending the
University Center at Ponca City campus is the Main Office and the contact is Adam Leaming.
Reference: Current NWOSU Undergraduate Catalog
Record of Arrest or Commitment for Mental Incompetence
Policy
It is the responsibility of the Division of Nursing to inform current and prospective students who
have been arrested / convicted, for any charge or have been committed by a court for mental
incompetence, of the rules and regulations of the Oklahoma Board of Nursing related to initial
licensure. (See next page – Information for Applicants for Licensure … with History of Arrests,
Convictions, or Prior Disciplinary Action)
Arrest/convictions include felonies or lesser charges.
If a student has been adjudicated as mentally incompetent or mentally ill (that is, committed by
a court as mentally ill), the student may be denied admission to the nursing program.
Any nursing student, regardless of medical history, is permitted to continue in the nursing
program if they can meet the objectives of the nursing course/program.
Faculty who are concerned with the welfare of the student with a “mental health history” have
the right to explore with the student the past health history, current treatment, and/or request a
recent statement from the student’s physician. The student may be referred for mental health
counseling.
Action
1. The student informs the Division of Nursing Chair of any records of arrests and/or
commitments for mental incompetence. NOTE: This is a requirement. Failure to do so may
lead to dismissal from the program.
2.The Division of Nursing Chair informs the student of the Oklahoma Board of Nursing rules
and regulations and the possible implications.
3.The Division of Nursing Chair assists the person in contacting the Oklahoma Board of
Nursing for further counseling if deemed necessary.
Reference: Current NWOSU Division of Nursing Student Handbook policy on record of arrest or
commitment for mental incompetence.
Academic year 16-17
27
For candidates with a History of Arrests/Convictions/Prior Disciplinary Action- refer to the
Oklahoma Board of Nursing’s policy effective January 2000 and found below:
Oklahoma Board of Nursing
2915 N. Classen Blvd., Suite 524
Oklahoma City, OK 73106
(405) 962-1800
www.ok.gov/nursing
INFORMATION FOR APPLICANTS FOR RN, LPN or APRN LICENSURE, AUA CERTIFICATION,
OR REINSTATEMENT WITH HISTORY OF ARRESTS, CONVICTIONS,
OR PRIOR DISCIPLINARY ACTION
Applicants for licensure, AUA certification, or reinstatement in Oklahoma who have ever been
summoned, arrested, taken into custody, indicted, convicted or tried for, or charged with, or pleaded
guilty to, the violation of any law or ordinance or the commission of any misdemeanor or felony, or
requested to appear before any prosecuting attorney or investigative agency in any matter; or have
ever had disciplinary action taken against a nursing license, certification or registration, any
professional or occupational license, registration, or certification and/or any application for a nursing
or professional or occupational license, registration, or certification or if there is currently any
investigation of your nursing license, registration, or certification; and/or any professional or
occupational license, registration, or certification; and/or any application for a nursing and/or
professional or occupational license, registration, or certification in any state, territory or country, or
have ever been judicially declared incompetent are required to notify the Oklahoma Board of Nursing
if the incident has not previously been reported in writing to the Board. A “report in writing” means that
the applicant/licensee provided a signed and dated description stating in his/her own words the date,
location, and circumstances of the incident, and if applicable, the resulting action taken by the court,
agency, or disciplinary board. The report may be in the form of a letter or a statement in the provided
space on the application. The report must be accompanied by certified court records or a board order.
A verbal report does not constitute a “report in writing”. A written report not accompanied by a full set
of certified court records or the board order(s) does not constitute a “report in writing”. Failure to
report such action is a violation of the Oklahoma Nursing Practice Act.
All applicants for licensure as a Registered Nurse, Licensed Practical Nurse or Advanced Practice
Registered Nurse or for certification as an Advanced Unlicensed Assistant, must have submitted a
fingerprint criminal history records search conducted by the FBI and Oklahoma State Bureau of
Investigation not more than three (3) months prior to submission of the application [59 O.S. §567.5].
A candidate for a license to practice as a Registered Nurse or Licensed Practical Nurse, or for
certification as an Advanced Unlicensed Assistant, shall submit to the Oklahoma Board of Nursing
“certified written evidence that the applicant has never been convicted in this state, the United States
or another state of any felony, unless five (5) years have elapsed since the date of the criminal
conviction or the termination of any probation or other requirements imposed on the applicant by the
sentencing court, whichever shall last occur, or a presidential or gubernatorial pardon for the criminal
offense has been received” [59 O.S. §567.5, 567.6, & 567.6a]. Therefore, individuals with one or
more felony convictions cannot apply in Oklahoma for RN/LPN licensure by examination or
endorsement, or for AUA certification, for at least five years after completion of all sentencing
terms, including probation and suspended sentences, unless a presidential or gubernatorial
pardon is received.
The applicant must submit the following information to the Board:
1. Application for licensure, certification or reinstatement, and fee;
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2. A signed statement from the applicant describing the location and circumstances of the offense,
date, court action or Board action taken and current status;
3. Fingerprint criminal history search not more than three (3) months old (applicable only to applicants
for licensure by examination, endorsement, APRN licensure or AUA certification); and
4. If applicable, certified copies of the Affidavit of Probable Cause, Information Sheet, Charges,
Judgment and Sentence, and verification that the sentencing requirements are complete (these
documents may be obtained from the courthouse in the county in which the arrest took place). Please
ensure that the copies are certified, e.g., they are stamped with the court seal. Internet print-outs are
not acceptable. If no records are found, have the agency provide a certified letter stating no records
found in a search from the date of offense through current date.
5. If applicable, copies of the licensing agency’s actions submitted directly from that agency to the
Oklahoma Board of Nursing
Please be aware that an applicant may not be eligible for licensure or endorsement to surrounding
states due to individual states’ restrictions, even if the applicant is able to be licensed in Oklahoma.
Individuals who plan to apply for licensure in other states must check with that state’s board of
nursing to obtain information on requirements.
Retrieved from ok.gov/nursing/nclex9.pdf 06/14
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NCLEX or AUA Certification Candidates With History of Arrest/Deferred Sentence/Conviction
Policy
OKLAHOMA BOARD OF NURSING
2915 N. Classen Boulevard, Suite 524
Oklahoma City, OK 73106
(405) 962-1800
NCLEX or AUA Certification Candidates
With History of Arrest/Deferred Sentence/Conviction Policy
I. Regulatory Services staff may approve the application of an NCLEX or AUA certification
candidate with a misdemeanor offense in the following cases:
A. First instance of a misdemeanor including but not limited to bogus checks, larceny of
merchandise, or violation of a state or federal narcotics or controlled dangerous
substance law; and
B. The misdemeanor offense was not plea bargained from an initial felony charge; and
C. The candidate has no other criminal charge(s), judgment, or sentencing pending.
Regulatory Services staff may, at their discretion, request further review by the Investigative
Division of any Application.
II. All other Applications of NCLEX Applicants or AUA certification candidates with arrest(s),
history of disciplinary action, and/or judicial declaration of mental incompetence, will be
reviewed by the Investigative Division and prosecuting attorney for a decision regarding
approval. The Investigative Division Staff may approve the Application of an NCLEX or
AUA certification candidate in the following cases:
A. The criminal charge resulting in deferred sentence or conviction was not for a felony
or misdemeanor involving physical harm to another; and
B. The conviction did not result in a sentence of incarceration that was served; and
C. The deferred sentence or conviction is older than ten (10) years and the Applicant
has successfully completed the terms of the sentence and has had no other
subsequent criminal offenses or unbecoming conduct.
If the deferred sentence or conviction is more than five (5) years old and involved alcohol
related incidents, the Applicant may be asked to submit to an Evaluation from an approved
provider that meets the criteria established by the Board. Upon receipt of the Evaluation, if
there are no recommendations for treatment or monitoring, the applicant will be approved
without disciplinary action. If the Evaluation has recommendations for treatment or
monitoring, the Applicant will be offered a Stipulated Order based upon the Evaluator and/or
IDP or Board recommendations.
III.
All other Applications of candidates with arrests, misdemeanors, felonies, history of
disciplinary action, or judicial declaration or mental incompetence, not falling within the
parameters of Sections I and II above, must come before the IDP or Board for decision.
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IV.
Regulatory Authority: 59 O.S. §567.8
Board Approved: 09/95
OBN Policy/Guideline #E-20
Board Reviewed w/o Revision:
Page 1 of 1
Board Revised: 1/2000; 9/01; 11/02; 1/05; 01/09; 11/09
H:/SEllis/Executive/Policies/Education/NCLEXAUAArrest
XI. Statement of Responsibility
The Division of Nursing of Northwestern Oklahoma State University is approved by the Oklahoma
Board of Nursing. Graduates of this state-approved program are eligible to apply to write the
National Council Licensure Examination (NCLEX) for (registered) nurses. Applicants for
Oklahoma licensure must meet all state and federal requirements to hold an Oklahoma license to
practice nursing. In addition to completing a state-approved nursing education program,
requirements include submission of an application for licensure with a criminal history records
search and successfully passing the licensure examination. Applicants for practical nurse
licensure must also hold a high school diploma or a graduate equivalency degree (G.E.D.) [59
O.S. §567.5 & 567.6]. To be granted a license, an applicant must have the legal right to reside in
the United States (United States Code Chapter 8, Section 1621). The Board has the right to deny
a license to an individual with a history of criminal background, disciplinary action on another
health-related license or certification, or judicial declaration of mental incompetence [59 O.S.
§567.8]. These cases are considered on an individual basis at the time application for licensure is
made, with the exception of felony charges. An individual with a felony conviction cannot apply for
licensure for at least five years after completion of all sentencing terms, including probation and
suspended sentences, unless a presidential or gubernatorial pardon is received [59 O.S. §567.5 &
567.6].
Regulatory Authority 59 O.S. §567.12
OBN Policy/Guideline #E-05
Board Approved: 7/92;
Revised 9/01, 5/04, 1/05, 6/11/04, 6/05, 6/14
Reviewed 7/06, 7/07, 08/09, 6/14
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CRIMINAL HISTORY BACKGROUND CHECKS
The facilities used by NWOSU for clinical experiences require students to pass criminal
background checks and drug screen tests. Such background checks and drug screens are clinical
practice site requirements, not requirements of NWOSU or the Division of Nursing. The clinical
facilities have specific requirements for the background checks and drug screens.
The Division of Nursing is responsible for providing acceptable training sites for its students,
preparing students appropriately for required licensure exams, and providing students with the
appropriate knowledge to practice their profession. It is the student’s responsibility to comply with
the criminal background check and drug test requirements. A student will not be allowed to
participate in clinical experiences without completion of these annual requirements.
The Division of Nursing is NOT responsible for finding clinical practice sites for students who are
unable to meet the requirements to pass the background check and/or drug screen. The Division
of Nursing does not assure that a graduate will be allowed to register for required licensure exams
or obtain required licenses to practice based upon the results of the background checks or drug
screens. Students should be aware that failure to pass a background check or drug screen will
prevent the student from participating in the clinical experience and may delay the student’s
completion of the degree program requirements or prevent the student from completing the
degree program.
A. BACKGROUND CHECKS FOR CLINICAL SITES
Background checks on each student are required by clinical sites to protect patients and the
general public. For this reason, clinical sites require you to have background checks
performed. The NWOSU Division of Nursing reserves the right to require repeat background
checks if needed. The background checks will allow, dissemination of self-disclosure
information, background check results, and conviction records to clinical training sites, whether
in or outside the state of Oklahoma as deemed necessary by the school. A background check
must be done before the All Division Meeting of the student’s Junior Year. In addition, a
Morpho Trust background check is required of graduating seniors making application for the
NCLEX examination. OU Medical System requires a Group I background check from Seniors
prior to an arranged Nursing Capstone practicum in an Oklahoma City health care facility. This
information may be provided to the clinical sites during the completion of the academic
program. The scheduled due dates for background checks will be available in the Division of
Nursing Office.
Conviction/criminal history records are reviewed as they relate to the content and nature of
the curriculum and the safety and security of patients and the public.
In addition, please be aware that the clinical sites reserve the right to refuse placement of any
student. If the student is unable to meet the clinical requirements it will result in not being able
to pass the course and the student will not be allowed to progress in the program.
The school reserves the right to request additional information as deemed necessary.
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Acknowledgement of
General Information Packet
I have read the General Information Packet that accompanies the NWOSU Division of Nursing
Application and acknowledge that I have an opportunity to ask questions about the information. I
understand that I may direct any additional questions to my advisor.
General Information Packet Includes:
I.
II.
III.
IV.
V.
VI.
General Information
The Oklahoma Board of Nursing Rules and Regulations
Core Performance Standards for Admission and Progression in the Nursing Program
Record of Arrest or Commitment for Mental Incompetence
Guidelines for NCLEX Candidates with History of Arrests/Convictions/Prior
Disciplinary Action
Certified Background Check
Please sign, date, and return this form to:
NWOSU
Division of Nursing
709 Oklahoma Blvd
Alva, OK 73717-2799
580-327-8493
______________________________
Student
Academic year 16-17
_______________________
Date
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