Nursing Support Technician - Certified - Permit by Exam

DEMOGRAPHICS Step 1 / 9

Mailing Address
Physical Address
Contact Information

CITIZENSHIP Step 2 / 9

Are you a US citizen?

ELIGIBILITY CRITERIA Step 3 / 9

For NST-C permit, have you graduated from an approved program in Alabama or an NST-C program in another jurisdiction or territory that substantially meets the same educational criteria as Alabama programs?
For the NST-C permit, do you have an employer attestation with date of program completion or date certificate awarded?


EMPLOYMENT Step 4 / 9

REGULATORY QUESTIONS Step 5 / 9

1
Excluding minor traffic violations*, have you (check all that apply):
(*Any crime related to driving while impaired or while under the influence of any substance is not a "minor traffic violation")
1-a
Been convicted of any crime in any state, municipality, territory, or country?

1-b
Entered a plea of guilty to any crime in any state, muncipality, territory, or country?

1-c
Entered a plea of nolo contendere or no contest for any crime in any state, municipality, territory, or country?

1-d
Received deferred prosecution or adjudication for any crime in any state, muncipality, territory, or country?

1-e
Had judgment withheld for any crime in any state, muncipality, territory, or country?

1-f
Received pretrial diversion for any crime in any state, muncipality, territory, or country?

1-g
Received any other alternative sentencing, supervision, or diversion program for any crime in any state, muncipality, territory, or country?

1-h
Stipulated to a prima facie case against you for any crime in any state, municipality, territory, or country?

1-i
Pleaded not guilty by reason of insanity or mental defect to any any crime in any state, municipality, territory, or country?

2
Has the licensing authority of any state, territory, or country denied, revoked, suspended, reprimanded, fined, accepted your surrender of, restricted, limited, placed on probation, or in any other way disciplined your nursing and/or any other occupational license, registration, certification or approval?

3
Is the Board of Nursing or other licensing authority of any state, territory or country, currently investigating you?

4
Is disciplinary action pending against you with the Board of Nursing or other licensing authority of any state, territory, or country?

5
Are you currently a participant in any alternative program (a nondisciplinary monitoring program approved by a licensing board)?

6
Are you now, or have you ever been, placed on a state and/or federal abuse registry or placed on the Office of Inspector General exclusion list?

7
Has any branch of the armed services ever administratively discharged you with any characterization of service other than "Honorable" and/or court-martialed you?

8
The ABN recognizes that nurses and other healthcare professionals encounter health conditions, including those involving career fatigue, burnout, mental health, physical health, and substance use disorders. The ABN strongly supports applicants and nurses’ efforts to address their health concerns and ensure patient safety through voluntarily seeking care and self-limiting their practice during times when their conditions may render them unable to safely practice nursing with reasonable skill and safety to patients. The failure to adequately address such a condition, where the applicant or nurse is unable to safely practice nursing with reasonable skill and safety to patients, may result in the ABN taking action against the applicant or nurse to ensure patient health and safety. Applicants or nurses who are unable to safely practice nursing with reasonable skill and safety to patients may also be eligible to participate in the ABN’s non-public Voluntary Disciplinary Alternative Program. By checking the “no” box, I attest that I have no physical, mental, or substance use disorder condition which currently impairs my ability to safely practice nursing with reasonable skill and safety to patients, with or without reasonable accommodation. If you are not able to make this attestation, please check the “yes” box, and a representative of the Voluntary Disciplinary Alternative Program will reach out to you at your contact information on file with the ABN. *Please note that VDAP is not available to MACs and NSTs.

TESTING LOCATION Step 6 / 9

PREVIEW Step 7 / 9

E-SIGNATURE Step 8 / 9

AFFIRM AND SUBMIT Step 9 / 9