007.03 APPLICATION AND DOCUMENTATION. To
reinstate a credential, an individual must submit a complete application, have
met the continuing competency requirements, and meet the requirements set out
in Neb. Rev. Stats. §
38-129
and §§
4-108
through
4-111.
007.03(A) INFORMATION. The individual must
submit the following information:
(i) Legal
name and any other names by which the individual is known;
(ii) Complete mailing address;
(iii) Social security number (SSN) or Alien
Registration Number (A#). Some individuals may have both a social security
number and an Alien Registration Number and if so, the individual must report
both;
(iv) Telephone number and
e-mail address;
(v) Whether the
individual holds a credential(s) in another jurisdiction(s) to provide health
services, health-related services or environmental services; and
(vi) If making application following
voluntary surrender or disciplinary action, information relating to what
actions the individual has taken to address the reasons that caused the
action.
007.03(B)
DOCUMENTATION. The individual must submit the following documentation and
information with the reinstatement application to the department:
(i) CITIZENSHIP OR LAWFUL PRESENCE.
Documentation that the individual meets the requirements set out in Neb. Rev.
Stats. §
38-129
and §§
4-108
through
4-111.
(ii) OTHER CREDENTIAL INFORMATION. If the
individual holds a credential to provide health services, health-related
services, or environmental services in another jurisdiction, provide the name
of the jurisdiction, credential number, type of credential, date issued, and
expiration date for each credential the applicant holds or has held;
(iii) DISCIPLINARY ACTION. If the credential
has been disciplined, a list of any disciplinary actions taken against the
individual's credential and a copy of the disciplinary action(s), including
charges and disposition;
(iv)
DENIAL. If the individual was denied a credential, an explanation of the basis
for the denial and a copy of the denial documentation;
(v) CONVICTION INFORMATION. If the individual
has been convicted of a felony or misdemeanor in Nebraska or another
jurisdiction since the credential was last renewed or since the effective date
of the disciplinary action was taken by the department, the individual must
submit:
(1) A copy of the entire court record
related to all misdemeanor and felony convictions;
(2) An explanation of the events leading to
the conviction (what, when, where, why) and a summary of actions that the
applicant has taken to address the behaviors or actions related to the
conviction;
(3) A letter from the
individual's probation officer addressing the terms and current status of the
probation, if the individual is currently on probation;
(vi) DRUG OR ALCOHOL RELATED CONVICTIONS. To
aid in the evaluation of an individual's drug or alcohol related conviction(s),
an individual may submit evaluation and discharge summaries where drug or
alcohol treatment was obtained or required. Evaluations and discharge summaries
may be submitted by the provider directly to the department.