REGISTERED NURSES' ASSOCIATION OF NOVA SCOTIA

College of Registered Nurses of Nova Scotia – Registration ServicesSuite 4005, 7071 Bayers Rd. Halifax NS, Canada B3L 2C2Telephone: 1-902-491-9744, ext 252 Toll Free: 1-800-565-9744 Facsimile: 1-902-491-9510E-mail address: ien@crnns.ca Website: www.crnns.caE. Status of Registration1.Have you ever been charged with, pleaded guilty to, been convicted of or found toYes No If yes, explainbe guilty of an offence in or out of Canada, for which you have not received apardon?2.Are you currently under investigation by any registration/licensing authority? Yes No If yes, explain3.Do you currently hold a licence with another health profession? Yes No If yes, explain4.Have you ever been disciplined by a registration/licensing authority forany occupation/profession in or out of Canada, or do you have anyconditions or restrictions on any licence that you currently hold?Yes No If yes, explain5.Have you ever been denied or had revoked any registration, licence, or permit? Yes No If yes, explain6.Were you ever disciplined by or expelled from any university or school of nursing? Yes No If yes, explain7.Have you ever been suspended or terminated from any employment? Yes No If yes, explain8.Is there, to your knowledge or belief, any event, circumstance or conditionconcerning your competence, character, capacity, conduct or reputation thatmay impact your registration as a registered nurse?IF ANSWERING “YES” TO QUESTIONS 1-8, PLEASE ATTACH AN EXPLANATION.9.Have you ever written the Canadian Registered Nurse Examination (RN exam)for registration in another Canadian jurisdiction?Yes No If yes, explainYes No If yes, explain10.Have you ever been required / asked by another regulatory body in Canada tocomplete a competence assessment? (e.g., a competence assessment of yourknowledge, skills and abilities using tools such as observation, interviews andwritten tests.)?11.Have you ever completed a competence assessment in another Canadian jurisdiction? Yes NoIf you answered yes to question #11, please arrange for a certified true copy of thefollowing to be forwarded to the College from the regulatory body as applicable:•all letters associated with the process;•the assessment report; and•transcripts of education completed to bridge the gaps identified in theassessment report.F. Nursing PracticeYes NoIf yes, answer question #11Please record the total number of actual hours worked as a registered nurse from November 1 to October 31 for thecurrent and previous five years.20 - hours (current year, to date of application) 20 - hours (three years previous)20 - hours (one year previous) 20 - hours (four years previous)20 - hours (two years previous) 20 - hours (five years previous)Rev 11/10