Oregon State Board of Nursing by rU8T4s

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									                                              Oregon State Board of Nursing
                                       17938 SW Upper Boones Ferry Road, Portland, OR 97224
                                       Phone 971-673-0685                Fax 971-673-0684
                     Email ginger.simmons@state.or.us                       Website www.oregon.gov/OSBN


                    OREGON PETITION FOR NON-OREGON BASED PROGRAMS
                        OFFERING CLINICAL EXPERIENCE IN OREGON
                                 Part A – Program Information
                                        If completing online, be sure to make a copy for your records.
Part A: Submit annually (fall term or first term of the academic year) only; Provide program information
and required documentation.
Part B: Submit for each student clinical placement; Provide clinical practicum information and required
documentation for each facility site and each preceptor.
Program / College / University Name:

Location (Street, City, State, Zip):

Mailing Address (if different):
Contact Name & Title:
Contact Phone Number:                                                  Contact Email Address:

Dean/Director Name:
                                                                       Dean/Director Email
Dean/Director Phone Number:
                                                                       Address:
Nursing Education Delivery Method:                On Ground                       Hybrid/Blended         Fully Online

                                  Fully approved by the Board of Nursing to           (date: mm/dd/yyyy)
     1. Status of                    ☐ Attach copy of letter and/or other documentation
  nursing program in              No Board Approval Mandated by State
     home state:                  Other –
                                     ☐ Attach documentation and/or explanation

                                  Fully accredited by         to        (date: mm/dd/yyyy)
                                      ☐ Attach copy of letter and/or other documentation
     2. Institutional             On provisional status; review scheduled for          (date: mm/dd/yyyy)
     Accreditation:
                                      ☐ Attach copy of letter and/or other documentation
                                  Accreditation removed by the certifying body
                                      ☐ Attach copy of letter and/or other documentation

                                  Fully accredited by     CCNE      NLNAC to          (date: mm/dd/yyyy)
                                     ☐ Attach copy of letter and/or other documentation
      3. Program                  On provisional status; review scheduled for        (date: mm/dd/yyyy)
     Accreditation:
                                     ☐ Attach copy of letter and/or other documentation
                                  Nursing Specialty program accreditation denied             (date: mm/dd/yyyy)
                                     ☐ Attach copy of letter and/or other documentation
                                  Not accredited by choice, no application submitted or denied




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                         Attach a copy of approval from the Oregon Office of Degree Authorization.
  4. Oregon Office of
 Degree Authorization: Contact: Jennifer Diallo, ODA Director
                       website: oregonstudentaid.gov/oda
                       phone: (503) 373-0072 ~ email: Jennifer.diallo@state.or.us
                       address: 775 Court Street NE, Salem OR 97301


                           Attach a Nursing Program Faculty Appointment form for each faculty member
                          providing direct clinical supervision in Oregon. (Link to form on OSBN website:
       5. Faculty                          http://oregon.gov/OSBN/pdfs/form/facultyappt.doc)
     Appointments:
                       Any faculty members providing direct clinical supervision in Oregon must meet all
                       standards for faculty in nursing programs, including holding an unencumbered license in
                       Oregon pursuant to the Oregon Nurse Practice Act.
                                   NCLEX first-time pass rates for the most recent two years**:
                             % for last year ending September 30 (e.g. tested between 10/01/2010 and 9/30/2011)
                             % for preceding year ending September 30 (e.g. tested between 10/01/2009 and
  6. RN/PN Programs    9/30/2010)
         Only:             -   Retrieve data from the quarterly NCLEX® Administration reports provided to
                               your state board)
                           -   **NOTE: Provide pass rates for the graduates from the type of program to
                               which this petition applies
Official Use Only
Date Received                                           Yes
                                   Approved:                               Date of Approval :
            :                                      No
     Comments:

    Signature:




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                                      Oregon State Board of Nursing
                            17938 SW Upper Boones Ferry Road • Portland, Oregon 97224-7012
                     Phone: 971-673-0685 • Fax: 971-673-0684 • License Verification: 971-673-0679
                          E-mail: ginger.simmons@state.or.us • Website: www.oregon.gov/OSBN


                      OREGON PETITION FOR NON-OREGON BASED PROGRAMS
                          OFFERING CLINICAL EXPERIENCE IN OREGON
                               Part B – Student Clinical Placement
                                    If completing online, be sure to make a copy for your records.
  Complete Part B for each student clinical placement. When there is more than one facility site and / or
            preceptor for the same student, Part B must be submitted for each placement.
Student Name:

Student Oregon                                                       License
                                                         NA
RN /PN License:                                                      Expiration Date:

Student Phone:                                                       Student Email:

Name of Student                                                      Student Program
Program Advisor:                                                     Advisor Title:
Student Program                                                      Student Program
Advisor Phone:                                                       Advisor Email:

                                              PROGRAM INFORMATION
Student Program / College /
University Name:
Student Program City/State:

                          Advanced                                    Acute Care           Adult                Nurse Midwife
                       Practice                     Sub-
                                                  Category            Family               Geriatric            Neonatal
     Nursing
  Program Type:            Registered Nurse        APRN
                                                  Programs            Pediatric            Psych/Mental         Women’s Health
                           Practical Nurse
                                                                      CRNA                 CNS                  Other

                         CLINICAL EXPERIENCE – OREGON AGENCY or FACILITY
Agency/Facility                                                       Contact Person
Name:                                                                 Name:
Address (Street,                                                      Contact Person
City, State, Zip):                                                    Position:
Contact Email                                                         Contact Person
Address:                                                              Phone Number:
Start Date:                                                           End Date:

                                       OREGON ASSIGNED PRECEPTOR
                                                                      Preceptor OR RN
Preceptor Name:                                                                                                            NA
                                                                      License:
                                                                      Preceptor OR AP
Preceptor Phone:
                                                                      or Other License:
Preceptor Email
                                                                      Expiration Date:
Address:
Preceptor                                                             Preceptor
Certification(s) or                                                   Agreement                      Yes   No       N/A
Specialty:                                                            Attached:



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                                      OREGON ASSIGNED FACULTY
                                                          Faculty OR RN
Faculty Name:
                                                          License:
                                                          Faculty OR AP or
Faculty Phone:
                                                          Other License:
Faculty Email                                             License
Address:                                                  Expiration Date:
Faculty Appointment Form and
Resume/CV Attached:
                                           Yes     No
Faculty Appointment Offer Letter or
Other Document of Agreement:
                                           Yes     No           Pending


Description of clinical site and experience:



Justification or rationale for use of Oregon facilities:



Describe the measures that will be used to assure client/student safety for the clinical
experience:



Anticipated faculty to student ratio applicable to students placed in Oregon facilities:



  REVIEW PROCESS INFORMATION
       Petition Status will be communicated to the program within three weeks of the date OSBN
        received completed petition.
       Students must contact their program directly for proof of required state approval before
        clinical starts. Failure to obtain approval is grounds for denial of clinical hours and civil
        penalty to preceptors/faculty.
Official Use Only
Date Received                                           Yes
                                      Approved:                              Date of Approval :
            :                                      No
     Comments:

    Signature:




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