Vermont Nurse Renewal Form – Fill Out and Use This PDF

Section B: Vermont Mandatory “Good Standing” Declarations

CHILD SUPPORT:

Child Support Orders (15 V.S.A. §795(c)): As of the date of this application: (you must check one)

Not Applicable – I am not subject to a child support order

I am in good standing*

I am in compliance with a payment plan approved by the Office of Child Support

I am NOT in good standing*

TAXES:

Tax Compliance (32 V.S.A. §3113(b)): As of the date of this application: (you must check one)

Not Applicable – I have never lived or worked in Vermont and do not owe Vermont taxes

I am in good standing*

I am in compliance with a payment plan approved by the Vermont Department of Taxes

I am NOT in good standing*

DISTRICT COURT FINES / JUDICIAL BUREAU:

Unpaid Judgments (4 V.S.A. §1110(b and c)): As of the date of this application: (you must check one)

Not Applicable – I do not have any unpaid judgments

I am in good standing* with the judicial bureau or district court for fines or penalties for a violation or criminal offense

I am NOT in good standing.*

*“Good standing” is defined in the statutes cited above. For more information, refer to the relevant statute specific to the particular question.

Name (print): ___________________________________

License Number: ___________________________

2

Section C:	Vermont Mandatory Credential and Fitness Questions
Please circle Yes or No for each of these questions. If the answer is “Yes,” follow the provided instructions.
Since you were originally licensed or since you completed your last renewal application:
Have you committed acts of abuse, neglect, or misappropriation of patient property?		Yes	No
If “Yes,” provide a detailed written explanation and attach all related documents.
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an
application by you for a license, certificate, or registration to practice a profession or occupation?		Yes	No
If “Yes,” you must attach a copy of the order or official notification of the action(s).
Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) restricted,
suspended, revoked, or taken any other disciplinary action against a license, certificate, or registration
that you hold or held in any profession or occupation?		Yes	No
If “Yes,” you must provide a copy of the order or official notification of the action.
Have you ever surrendered a license, certificate, or registration to a licensing authority?
		Yes	No
If “Yes,” you must provide a detailed written explanation.
Are you currently under investigation by a licensing authority?
If “Yes,” you must provide a detailed written explanation and a copy of any available information from the		Yes	No
licensing authority.
Have you been convicted of a crime other than a minor traffic violation? (Note: Driving While Intoxicated
and Driving Under the Influence are not “minor traffic violations.”)		Yes	No
If “Yes,” you must provide a detailed written explanation and attach the official court documents.
Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)?
		Yes	No
If “Yes,” you must provide a detailed written explanation and attach a copy of the charging documents.

Note: Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. §129a(a)(11).

The answers to the following questions are not subject to public disclosure

Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to
practice this profession with reasonable skill and safety?
		Yes	No
If “Yes,” you must have your health care provider submit a detailed statement explaining how you are
able to practice safely.
Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice
this profession with reasonable skill and safety?		Yes	No
If “Yes,” you must provide a detailed written explanation.
Are you currently addicted to or in any way dependent on alcohol or habit forming drugs?
		Yes	No
If “Yes,” you must provide a detailed written explanation.
Are you currently participating in a supervised program or professional assistance program which
monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances?		Yes	No
If “Yes,” please provide the contract/stipulation under which you are practicing.

Name (print): ___________________________________

License Number: ___________________________

3

Section D: RN Nursing Education and Practice Requirements

Board of Nursing Administrative Rules, Part 9 Education and Practice Requirements, Rule 9.1 (b) and(c)

Practice of nursing at the level of licensure within the past five years means practice as described in 26 V.S.A. § 1572, definitions, for at least 120 days, 960 hours, in the five years prior to the expiration date or 50 days, 400 hours, within the two years prior to the expiration date. Eight hours are equivalent to one day of nursing practice.

Program and Practice Experience Requirement

(Check the box that applies to your license.)

I have completed my original/initial Nursing program or a Re-entry program within the last five (5) years; therefore I do not have to meet the practice experience requirement (4/1/2008 – 3/31/2013).

I have practiced as a Registered Nurse for 50 days (400 hours) within the last two (2) years OR 120 days (960 hours) within the last 5 years.

I have NOT met the program or practice experience requirement

(You must contact the Board office at 802-828-2396)

Section E: Audit Information

The Office of Professional Regulation reserves the right to verify information submitted by licensees for renewal through a random employment audit. You must retain all names and complete dates of employment for the five years prior to this renewal application. To assist you in documenting your practice hours, please download the “RN Practice History Record” form from our website at www.vtprofessionals.org/opr1/nurses.

If you are selected for an audit, a form will be sent to you requiring the names and addresses of all employment for the past five years which you have used to satisfy your practice hour requirements and you will have to report the name and title of your nursing supervisor.

For Private Duty you will need the following:

1.An Official letter from the client/patient’s attending Physician or Advanced Practice Registered Nurse (APRN) on their letterhead, stating that RN care was required. The letter must clearly list the Physician or APRN name, title, contact telephone number and have their signature.

2.A letter from your Employer or Client, verifying your role and duties as a Private Duty Nurse. They must verify the number of days, hours and dates worked. The letter must clearly list the Employer/Clients name, contact telephone number, email address, mailing address and have their signature.

For Volunteer Duty you will need the following:

An Official letter from your Employer sent directly to the Vermont Board of Nursing office from the Director of Nursing or Director of Human Resources. A copy of your Job Description as a Volunteer Nurse, and a letter listing the number of days, hours and dates worked. The letter must clearly list the name of the Director of Nursing or Director of Human Resources, their telephone number, email address, mailing address and have their signature.

Name (print): ___________________________________

License Number: ___________________________

4