crnbc

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Nurse Registration in British Columbia  Application Package for Internationally-Educated Nurses Not Registered in Canada This package contains the following:

Form 16: Application to be Assessed for Nurse Registration in British Columbia Form 49: Payment Form

Form 25: Verification of Nurse Registration Form 30: Basic Nursing Education and Request for Transcript Form 37: Employment Reference for Nurse Registration

English Test Fact Sheet

Are you applying to the correct regulatory body? Is your legal title one of the following? • Licens Licensed ed pra practi ctical cal nur nurse se • Reg Regist istere ered d psych psychiat iatric ric nurse nurse • Re Regi gist ster ered ed m mid idwi wife fe If one of these is your legal title, and you are NOT also a registered nurse, you need to check if  you should be applying to another regulatory body in British Columbia. Other regulatory bodies include the College of Licensed Practical Nurses of British Columbia, the College of Registered Registered Psychiatric Nurses of British Columbia, and the College of Midwives of British Columbia. You can find links to most of these organizations on the CRNBC website www.crnbc.ca If you are not sure whether CRNBC is the appropriate regulatory body to which you should be applying, e-mail register@crnbc to ask before submitting an application.

 Avoid delays in processing your application. Be sure to complete ALL the steps listed here before mailing your  application to CRNBC.

1. Complete Form 16. Do not leave any sections blank. Print neatly and legibly in ink. Be sure that the name you print on your application form is exactly the same as the name on the proof of identification you submit (i.e., your  passport, permanent residency papers, or citizenship papers). If your name has changed, you must submit documents that show your legal name. 2. Be sure to sign both the Consent for Information and Declaration on page 9 of Form 16. 3. Complete Form 49. Note that the assessment fee is non-refundable. 4. Complete Part A of Form 25 and send copies to all jurisdictions in which you have been registered or licensed. 5. Complete Part A of Form 30 and send it to your school of nursing. 6. Complete Part A of Form 37 and send it to your current and/or previous employer(s). 7. If English is not your first language, arrange to have your test scores from a test of English fluency sent to CRNBC. For information on acceptable tests, see the English Tests Fact Sheet. Include a copy of your passing score with your application for  registration. Your test scores cannot be be more than one year old at the time of application.

1. Your completed Form 16. 2. Your completed Form 49, including your non-refundable fee. The fee must be paid in Canadian funds and can be paid by credit card, money order or bank draft. Your application will not be assessed until the fee is paid in full. 3. You must list your current and all former names. CRNBC accepts photocopies of any of of the following documents as proof of identity: birth certificate; passport; Canadian immigrant visa and record of landing; Canadian permanent resident card; Canadian confirmation of permanent residence; marriage certificate; government issued change of name certificate. Only one document is required as proof for each name listed. 4. If required, test scores from your English language fluency test

CRNBC Registration Inquiry and Discipline 2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Visit the CRNBC website at www.crnbc.ca If you have questions about the application process or examination, contact: CRNBC Registration Inquiry and Discipline Tel: 604.736.7331 Toll-free (in Canada only): 1.800.565.6505 E-mail: [email protected]

07W30 (July 2010)

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Form 16

Application to be Assessed for Nurse Registration in British Columbia (Internationally Educated Nurses Not Registered in Canada) How to complete this form 1.

You must answer ALL questions on this form. Do not leave any sections blank.

2. Use dark ink and print your answers neatly. If you make a mistake, cross it out and print the correction version beside the cross-out. You can also obtain another copy of the form at http://www.crnbc.ca/Registration/RNAppli cation/InternationalEN/Pages/Step2.aspx and start again. 3.

Sign the Consent on page 8 allowing the CRNBC to request information from your current or previous employers.

4.

Sign the Declaration on page 8 of the form.

5.

Sign the Consent for Substantially Equivalent Competency Assessment on page 8.

6. Return the completed form to: CRNBC Registration, Inquiry and Discipline 2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

NOTE: If you fail to answer any question on this form, or if you do not sign the Consent and Declaration sections at the end of the form, or if you do not include Form 49: Payment Form with full payment and a copy of your passing English fluency test scores if required, your application will be returned to you and will be delayed.

page 1 of 8

o7w24-INTL ( Oct 10)

Full name as shown on your passport, permanent residency papers or citizenship papers (do not use initials).

______________________________________________________________________________________________________________ Last Name

First Name

Middle Name

Former Names if any (e.g., birth name or secular name as noted on birth certificate). ______________________________________________________________________________________________________________ Preferred name, if different than above _____________________________________________________________________________ Address ______________________________________________________________________________________________________ Apt./Box No.

Number

Street

______________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Telephone (include country code) __________________________________________________________________________________ E-mail ________________________________________________________________________________________________________ Preferred method of communication

E-mail

Regular Mail

Date of Birth (day/ month/year) ___________________________________________________________________________________ Place of Birth (city/town and country) ______________________________________________________________________________ Gender

Female

Male No

Yes

No

Yes

NOTE:  You MUST answer this question. If you answer “yes,” we will send to you worksheets requesting additional information once we receive your application. You do not have to send any other information regarding the criminal offence with this application. Alternatively, you can download the worksheet at www.crnbc/Registration/Lists/RegistrationResources/form75 infoonCriminaloffences.pdf 

First Language

English

Other (specify) _______________________________________________________________

NOTE: If English is not your first language, you must write and pass an English fluency test. You must send proof of your  English fluency (a copy of your passing marks from an accepted test or English fluency) with this application.

Copy of passing test enclosed (This test score should not be more than one year old) See the English Tests Fact Sheet www.crnbc.ca/Registration/RNApplcation/InternationalEN/Pages/Default.aspx

Personal Security Word __________________________________________________________________________________________ Choose a word that you will easily remember (e.g., your mother’s maiden name). CRNBC uses your personal security word to prote ct the privacy of your information. You will be asked to give this security word when you call, write, or e-mail to ask about your  application or to change your address.

page 2 of 8

Primary/Elementary School Secondary/High School Post-Secondary Education

Complete for all programs or schools attended. Attach another page if more space is needed.

Diploma/Certificate

__________________ Degree

__________________ Diploma/Certificate

__________________ Degree

__________________

page 3 of 8

Answer all questions. If not applicable, write “N/A.” 1.

Where and when did you first obtain your registration as a registered nurse? ________________________________________________________________________________________________________ State/province/country

Date

2.

What is your legal nursing title in the province/state/country in which you first obtained registration? __________________

3.

Where is your current place of registration? ___________________________________________________________________

4.

Have you applied for registration in another Canadian province/territory? No

5.

Yes If “yes,” which provinces/territories? ________________________________________________________

Have you been referred for a competency-based assessment in another Canadian province/territory? No

Yes If you completed a competency-based assessment, please arrange to have the assessment documents sent

directly from the source to CRNBC. 6.

Have you ever written the Canadian registration examination? No

Yes If “yes,” give dates and locations of all previous writings: ______________________________________

________________________________________________________________________________________________________ 7.

Do you have a physical or mental condition or disorder that impairs your ability to practice nursing competently and safely? No

8.

If yes, attach an explanation

Do you have an addiction to alcohol or drugs that impairs your ability to practice nursing competently and safely? No

9.

Yes

Yes

If yes, attach an explanation

Is your nursing conduct or practice currently under investigation? No

Yes

If yes, attach an explanation

10. Have you even been denied registration? No

Yes

If yes, attach an explanation, including copies of official notifications, orders, and decisions, and, if  applicable, whether or not you have had your registration reinstated

11. Have you ever been disciplined by a professional regulatory body? No

Yes

If yes, attach an explanation, including copies of official notifications, orders, and decisions, and, if  applicable, whether or not you have had your registration reinstated

12. Has your registration ever been revoked or suspended or had conditions attached? No

Yes

If yes, attach an explanation, including copies of official notifications, orders, and decisions, and, if  applicable, whether or not you have had your registration reinstated

11. Have you ever been registered with any other profession (e.g., social work, RPN, LPN)? No

page 4 of 8

Yes If yes, what profession? ___________________________________________________________________ )

For m 16 D. NURSING E XPERIENCE Total Hours Wor ked for the Past Five Year s Record the total number of hours for each year you actually worked, both in a paid job or as a volunteer, in nursing (as a graduate or  registered nurse) from January to December in each year. Do not include hours as a student nurse. Write “N/A” if no hours worked.

 Year  (  Januar y to December)

Total number of hours worked in calendar year 

2009 2008 2007 2006 2005

Nursing Employers Over the Past F ive Years (2005-2009 ) Provide all the required information for employers over the past five years (use another form if more space is needed to list all employers.) Include both paid and unpaid positions held. Please list chronologically. Attach another page if more space is needed.

NOTE: You must complete From 37: Employment Reference for Nurse Registration for your current or latest employer for  whom you have worked at least three months in the last five years. Only one employment reference is required.

1. Date Started (month/year) ______________________________ Date Ended (month/year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Address __________________________________________________________________________________________ Number

Street

____________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Employer’s E-mail Address ______________________________________________________________________________________ Name of Manager or Supervisor _________________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status of Applicant

Full-time

Part-time

Casual

Primary Language Spoken by Applicant ___________________________________________________________________________ Reference requested (Form 37)?

Yes

No

Registered as registered nurse by ________________________________________________________________________________ Verification of nurse registration requested (Form 25)?

page 5 of 8

Yes

No

2. Date Started (month/year) ______________________________ Date Ended (month/year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Address __________________________________________________________________________________________ Number

Street

____________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Employer’s E-mail Address ______________________________________________________________________________________ Name of Manager or Supervisor _________________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status of Applicant

Full-time

Part-time

Casual

Primary Language Spoken by Applicant ___________________________________________________________________________ Reference requested (Form 37)?

Yes

No

Registered as registered nurse by ________________________________________________________________________________ Verification of nurse registration requested (Form 25)?

Yes

No

3. Date Started (month/year) ______________________________ Date Ended (month/year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Address __________________________________________________________________________________________ Number

Street

____________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Employer’s E-mail Address ______________________________________________________________________________________ Name of Manager or Supervisor _________________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status of Applicant

Full-time

Part-time

Casual

Primary Language Spoken by Applicant ___________________________________________________________________________ Reference requested (Form 37)?

Yes

No

Registered as registered nurse by ________________________________________________________________________________ Verification of nurse registration requested (Form 25)?

page 6 of 8

Yes

No

List all other professional experience in nursing since graduation from your nursing program. Please list chronologically. Attach another page if more space is needed. 1. Date Started (month/year) ______________________________ Date Ended (month/ year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Location (city, state, country) __________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status

Full-time

Part-time

Casual

Verification of nurse registration requested (Form 25) if different than above?

Yes

No

2. Date Started (month/year) ______________________________ Date Ended (month/ year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Location (city, state, country)__________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status

Full-time

Part-time

Casual

Verification of nurse registration requested (Form 25) if different than above?

Yes

No

3. Date Started (month/year) ______________________________ Date Ended (month/ year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Location (city, state, country)__________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status

Full-time

Part-time

Casual

Verification of nurse registration requested (Form 25) if different than above?

Yes

No

4. Date Started (month/year) ______________________________ Date Ended (month/ year) _____________________________ Employer’s Name _____________________________________________________________________________________________ Employer’s Location (city, state, country)__________________________________________________________________________ Position Held by Applicant __________________________________________Unit/Area ___________________________________ Status

Full-time

Part-time

Casual

Verification of nurse registration requested (Form 25) if different than above?

page 7 of 8

Yes

No

I, (your name) ____________________________________________________________consent to any of my previous employers or my present employer to release information to the College of Registered Nurses of British Columbia regarding my competency in nursing and confirmation of employment to be used solely for the purpose of assessing my application for registration as a nurse in British Columbia. I swear the information on this form is true. Signature ________________________________________________________Date________________________________________

I, (your name) ____________________________________________________________am applying for r egistration in British Columbia. I swear that I am the person referred to in this application for registration as a registered nurse in British Columbia, that the statements are true, and that I have read and understand this declaration. I understand that (1) falsification of this application, or (2) the submission of any falsified documents or information to the CRNBC, or (3) the submission of any falsified CRNBC documents to other agencies may be cause for CRNBC to withhold or revoke registration, or to take other appropriate action.

Signature ________________________________________________________Date________________________________________

Applicants for registration who cannot be fully assessed based on the documentation provided may be required to undergo a Substantially Equivalent Competency Assessment (SEC) to determine eligibility for registration with CRNBC. If you are requested to undergo a SEC, you will be required to sign a consent. By signing this consent now you will avoid delaying your application if a SEC assessment is required at a later date. For information on the SEC assessment process, see www.nursinginbc.ca I, (your name) ____________________________________________________________ understand that if further information is required to assess my application for registration, I will be required to complete a full or partial substantially equivalent competency assessment. I understand that this assessment can only be completed in British Columbia. I agree to: 1.

my contact information and assessment requirements being provided to the B.C. IEN Assessment Service provider, and

2.

the B.C. IEN Assessment Service provider providing the results of my assessment to CRNBC.

Signature ________________________________________________________Date________________________________________

page 8 of 8

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Payment Form – International Nurse Assessment Applicant’s Name (print)________________________________________________________________________________



$560 ($500 + 60 HST) Application Assessment Fee (non-refundable)

Payment by:  Visa



Mastercard

Please charge $560 to my





American Express

VISA —

Credit Card Number 





MASTERCARD —

Bank Draft/Money Order (Payable to CRNBC)



AMERICAN EXPERESS —

Expiry date_______________________________ month/year 

Cardholder’s Name____________________________________________________________________________________ Signature________________________________________________Date_________________________________________  You must sign here if paying by credit card

Page 1 of 1

06w35-INTL (December 2010)

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Verification of Nurse Registration Complete Part A of this form and forward a copy to each regulatory body i n which you have been registered/ licensed.

Name ________________________________________________________________________________________________________ Last Name

First Name

Middle Name

Former Name if any __________________________________ _______________________________________ ___________________ Address ______________________________________________________________________________________________________ Apt./Box No.

Number

Street

______________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Telephone (include country code) ___________________________________E-mail ________________________________________ Date of Birth (day/month/year) ____________________________________ _____________________________________ __________ Nursing school where you completed your basic program ___________________________________ __________________________ Date Graduated (month/year) ___________________________________ _______________________________________ __________ Initial Nurse Registration Date (day/month/year)_____________________________________________________________________ Nurse Registration Number_______________________________________________________________________________________ Date

______________________________________ _Signature _________________________________ ______________________

I am applying for nurse registration in British Columbia. A record of my nurse registration is required .

Complete Part B of this form and mail it to CRNBC Reg istration, Inquiry and Discipline.

Name of Regulatory Body Name of Registrant

Registration Number 

Type of Registration Granted (title) Initial Registration Date Registered by

Expiry Date of Registration Examination

Endorsement

Has this person’s registration/licence ever been denied, revoked, suspended o r  under review? Examination Written

CAN Testing Service

NLN State Board Test Pool

NCLEX

No

Yes

Other (specify)

Number of Writings _____________________________________ __Passing Score__________________________________________ Name of Registrar or Person Completing this Form __________________________________ _________________________________ Title

__________________________________________________________________Date

07w21 (Apr 08)

page 1 of 1

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Basic Nursing Education and Request for Transcript Complete Part A of this form and send it to the s chool of nursing where you received your basic nursin g education. If you have taken additional courses or programs (e.g., midwifery or psychiatric nursing), send a copy of this form to the institution where you completed the course or program.

Name ________________________________________________________________________________________________________ Last Name

First Name

Middle Name

Former Name if any _____________________________________________________________________________________________ Address ______________________________________________________________________________________________________ Apt./Box No.

Number

Street

______________________________________________________________________________________________________________ City/Town

Province/State

Country

Postal/Zip Code

Telephone (include country code) ____________________________________E-mail ________________________________________ Date of Birth (day/month/year) ____________________________________________________________________________________ Nursing school where you completed your basic program ______________________________________________________________ Date Graduated (month/year) _____________________________________________________________________________________ Date

_________________________________________ Signature _____________________________________________________

Complete Part B of this form and send it wi th a and Discipline.

transcript directly to CRNBC Registration, Inquiry .

Type of School (e.g., college, university, vocational, hospital) Date Applicant Started Program _______________________________ Date Graduated ___________________________________ month/year

Type of Program

Degree

month/year 

Diploma

Certificate

Check the boxes below if this student completed theory and/or clinical practice in each of the areas listed. If the program did not include a total of 500 theory hours and 1,000 clinical practice hours in the areas listed, please indicate the number of hours for each area in the space provided. If any areas were combined or integrated, estimate the hours for each area. (state number of hours if total is less than 500)

(state number of hours if total is less than 1,000)

Adult Medical (including specialty areas)

_________________________

_________________________

Adult Surgical (including specialty areas)

_________________________

_________________________

Maternal/Newborn

_________________________

_________________________

Children/Pediatric)

_________________________

_________________________

Mental Health/Psychiatric

_________________________

_________________________

Community/Public Health

_________________________

_________________________

Gerontology

_________________________

_________________________

________________________

________________________

TOTAL HOURS

Name of Registrar or Person Completing this Form ___________________________________________________________________ Title

__________________________________________________________________ Date

07w23-INTL (Apr 08)

page 1 of 1

2855 Arbutus Street Vancouver, BC Canada V6J 3Y8

Tel: 604.736.7331 Toll-free: 1.800.565.6505 Fax: 604.736.3576 www.crnbc.ca

Employment Reference for Nurse Registration Applicant must have worked as a registered nurse for this employer for a minimum of three (3) months within the last five (5) years.

Part A – To be completed by Applicant only  After completing Part A, give this form to an employer for whom you have worked as an RN within the past five years. The completed form must be sent to CRNBC directly from the emp loyer.

Name: __________________________________________________________________Date____________________________________ Former name(s): __________________________________________ Date of Birth_____________________________________________ day

month

year 

Employee num ber (if known): _____________________________________ _____________________________________ ____________

Part B – To be completed by Employer only  After completing Part B, the employer must forward the completed Form 37 directly to CRNBC. If mailing, please use a corporate envelope or sign over the seal. If faxing, please use a corporate cover page. CRNBC must be able to confirm that this form was sent directly from the employer or it will not be accepted.

Employer: _______________________________________________________________________________________________________ Position held by applican t: ________________________________ ____Unit/Area: ____________________________________ ______ Is this a registered nurse position YES

NO

Applic ant employed from: ______________________ _______________To: ____________________________________ ____________ month/year

month/year 

Number of hours worked per year as a registered nurse _________________________________________________________________

__________________________________________________________________________ Title:

__________________________________________________________________________________________________________

Signature: __________________________________ ________________________Date: _________________________________ ______ Address of employer: _____________________________________________________________________________________________ no./street

city/town

__________________________________________________________________________________________________________ province/state/country

postal/zip code

Telephone: __________________________________ ____________E-mail: ______ _____________________________________ ______ (optional) _____________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ : CRNBC Registration, Inquiry and Discipline 2855 Arbutus Street, Vancouver, BC, Canada V6J 3Y8 Fax: 604.736.3576 Page 1 of 1

05W 57-CDA/INTL (Sep 09)

English Tests Effective proficiency tests:

, CRNBC will only accept the following two English



Canadian English Language Assessment for Nurses (CELBAN)



International English Language Testing System (IELTS

–

Academic version)

The scoring for both of these tests will be different from what appears below.









Applicants for CRNBC registration must meet English fluency requirements at the time of  application for registration. If English is not your first language, an English fluency test is required to confirm your proficiency in English. Allow several months to complete the English testing requirement. This includes the time from the initial enquiry at a test centre until the test scores are received by CRNBC. Results from combining tests are not accepted.

CRNBC has approved the following English proficiency tests until

:

Canadian English Language Benchmark Assessment for Nurses (CELBAN) www.celban.org 

Speaking Listening Reading Writing 

8 9 8 7

Contact: The CELAS Centre Language Training Centre Red River College Suite 400-123 Main Street Winnipeg, MB R3C 1A Tel: 204.945.0588 E-mail: [email protected]

1 College of Registered Nurses of British Columbia

International English Language Testing System (IELTS - Academic Version) www.ielts.org/ 

Tests English skills in reading, writing, listening and speaking

-

Minimum overall test score = 6.5

-

Minimum speaking test score = 7

-

No score can be lower than 6

Test of English as a Foreign Language (TOEFL)/Test of Spoken English (TSE) www.ets.org TOEFL – Internet Based Test (iBT) 

Measures English skills in reading, listening, speaking and writing

-

Minimum combined for reading, writing and listening = 60

-

Minimum score for speaking = 26

TOEFL – Paper Based Test (PBT) with Test of Spoken English (TSE) 

TOEFL measures English skills in reading, listening and writing



TSE measures English skills in speaking and complements the paper-based TOEFL



Minimum TOEFL score = 213 (computer-based test) = 550 (paper-based test)

Minimum TSE score = 50

Contact: TOEFL/TSE SERVICES P.O. Box 6155/6151 Princeton, NJ, USA 08541-6155 Tel: 609.771.7100 E-mail: [email protected]

Michigan English Language Assessment Battery (MELAB) www.lsa.umich.edu/eli/testing/melab 





Assesses English skills in composition, listening, grammar/reading and speaking if required.

-

Minimum score for composition, listening, grammar/reading = 83

-

Minimum score for speaking = 3

When applying for an English proficiency test, please arrange to have your test scores sent to CRNBC. CRNBC’s institution code is 9115. Test scores are valid for two years. Use the most current scores when applying to CRNBC. If  the scores expire during the application process, you may need to repeat the English proficiency test. Please attach a photocopy of your passing test results to your application

2 College of Registered Nurses of British Columbia

for registration. CRNBC must receive this to accept your application for registration. CRNBC will also require an official copy from the test provider.







IELTS preparation materials are available from the Simon Fraser University IELTS Test Centre www.sfu.ca/ielts Other preparation materials and information can be found in most public libraries. ESL/EAL (English as a Second Language/English as an Additional Language) classes may  also be helpful.

© Copyright College of Registered Nurses of British Columbia/Dec 2010 2855 Arbutus St., Vancouver, BC V6J 3Y8 Tel 604.736.7331 or 1.800.565.6505 Fax 604.738.2272 www.crnbc.ca Pub. 501 (INTL)

3 College of Registered Nurses of British Columbia