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Revised June 2021 GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS -----●----- DEPARTMENT OF HEALTH Virgin Islands Board of Nurse Licensure P.O. Box 304247 St. Thomas, Virgin Islands Telephone #: (340) 249 0684 extensions 5682/5683 Memo To: Advanced Practice Registered Nurses (APRN) and Registered Professional Nurses (RN) From: Virgin Islands Board of Nurse Licensure: Date: June 2021 Re: Renewal of APRN and RN Registration Certification (License) All nurses are responsible for the biannual renewal of nursing registration licenses/certificates for either ACTIVE or INACTIVE status even though a renewal application might not have been received by mail. Renewal applications are available from the office of the Virgin Islands Board of Nurse Licensure (VIBNL). and the Human Resources departments at the Governor Juan F. Luis Hospital and Medical Center, Schneider Regional Medical Center, and the Virgin Islands Department of Health. Note: The physical address of the VIBNL is VI Medical Foundation, 9150 Estate Thomas, 2nd Floor, Ste 206, St. Thomas, VI 00802. It is a violation of the Virgin Islands Code to work with a lapsed Registration Certificate (License). See Lapsed Registration on page 2 for further information. Discipline: Self disclosure is required for all misdemeanours, felonies, plea agreements (even if adjudication was withheld), and any substance use disorder within the last five (5) years. All complaints or disciplinary actions taken or pending against professional or occupational license(s), registration(s), or certification(s) must be disclosed. Failure to do so may result in a disciplinary action by the VIBNL Registration Fee: The fees for renewal of Registration Certificates (Licenses) for active/inactive status are as follows: • Registered Nurse: $125.00 • Advanced Practice Registered Nurse: $150.00 • Inactive Fee $15.00 Office Hours: Monday through Friday, 8:30 am – 4:00 pm. The Board’s office will be closed to the public for end-of-year reconciliation from December 20th, 2021 through January 2nd, 2022 and will reopen on January 3rd, 2022. Application Deadline: Note: Completed renewal packets should be returned to the VIBNL as soon as applicants have fulfilled all stipulated renewal requirements. Although current biennium Registration Certificates do not expire until December 31st, 2021, to ensure receipt of your 2022- Revised June 2021 2023 Registration Certificate prior to the expiration date, renewal applications must be received by the VIBNL no later than October 31, 2021. This allows adequate time for the VIBNL to complete administrative review, processing and mailing of the Registration Certificate prior to the end of the current biennium. Registration Certificates for the 2022-2023 biennium may not be able to be processed by January 1st, 2022 if renewal applications are received by the VIBNL after October 31, 2021. Lapsed Registration for active license: Active licensure renewal applications that are complete but postmarked after December 31, 2019 will be considered LAPSED and will require submission of a lapsed penalty fee of $200.00 in addition to the renewal fee in order to renew the license. Inactive Status: Nurses who apply for an Inactive Registration Certificate (License) must complete a renewal application and submit the inactive registration fee of $15.00 by the December 31, 2021. If not renewed by the December 31st deadline, an additional $30.00 lapsed registration fee plus the $15.00 inactive fee must be submitted. Signature: Signature and date of signature must be included on all renewal forms or the application will be considered incomplete and will not be processed. Fees are Non-Refundable and Non-Transferrable and are payable only by U.S. Postal Service money order, or certified bank check. Personal checks and international payment instruments will NOT be accepted. CONTINUED COMPETENCY FOR REGISTRATION CERTIFICATE RENEWAL MUST INCLUDE COMPLETION OF TWO (2) OF THE FOLLOWING: 1. Continuing Education Continued Competency: The Continuing Education Record must be completed and submitted with the renewal application. Certificates of Completion SHOULD NOT be included with renewal application however, random file audits will be conducted and those licensees whose files are audited, will be required to produce hard copies of ALL Certificates of Completion for contact hours listed on the renewal form. Failure to produce valid Certificates of Completion may result in disciplinary action. DOCUMENTATION OF CONTACT HOURS and PROVIDER NUMBERS must be included on the Continuing Education Record or the renewal application will be considered INCOMPLETE and it will not be processed until completed . RNs: Fifteen (15) contact hours of continuing education related to nursing practice. Contact hours ours maybe obtained online, by attending workshops, or through individual study (e.g. certification preparation). 1.5 hours must be related to the prevention of medication errors. APRNs: Thirty (30) contact hours of continuing education within the specialty area of nursing practice and submission of proof of current national certification within that specialty. 1.5 hours must be related to the prevention of medication errors. New Graduates: Nurses who graduated and received their initial license during the prior biennium are not required to complete the continuing education requirements for renewal. College Credit(s): Any nursing or health-related college credits* completed within the Revised June 2021 biennium may be utilized using the following equation: number of course credits x length of course (in weeks). Example: 3 credits x 15 weeks = 45 CEUs 2. Verification of Employment or Professional Activities Three hundred twenty (320) hours of active nursing practice in the previous biennium which must be certified by the supervisor or designee on the Employer Verification section of renewal application. APRNs are required to submit an updated Collaborative Agreement. OR Participation in fifteen (15) hours of approved professional activities documented and certified by supervisor, client or manager of the activity, or organization on the Professional Activity Form obtainable from the VIBNL. Refresher Courses: Nurses who have not been engaged in ACTIVE nursing practice during the last five (5) years, and who want to return to ACTIVE nursing practice, must complete a one-hundred and sixty (160) hour refresher course that includes both theory and clinical hours and that is pre- approved by the VIBNL. License Re-activation: Any license that has been inactive for more than ten (10) years shall automatically be suspended. To re-activate a defunct license, applicants must complete all requirements needed for an active license and submit supporting documentation. Official Verification: Lapsed and Inactive applicants not residing within the territory of the US Virgin Islands are required to submit a copy of an unencumbered nursing license that is valid for at least 90 days from the date on the renewal application and an Official Verification (obtainable at www.nursys.com ). Fees associated with Official Verification are the responsibility of the applicant. Name Change: Official supporting documentation (e.g. marriage license, divorce decree) must be submitted to the VIBNL immediately upon any change of name. Address Change: The VIBNL must be notified immediately in writing of any change in address and/or telephone number. Changes may be submitted via mail or email. Note: contact the VIBNL by phone for appropriate email address. Temporary phone number (340) 249-0680 extension 5682, 5683, or 5681. Communication: Should you have questions, need clarification, or directions to the office of the VIBNL, please do not hesitate to contact the Board staff. We are committed to keeping you informed about the renewal of your registration. Additional Contact Information: Physical Address: VI Medical Foundation, 9150 Estate Thomas, 2nd Floor, Suite 206 St. Thomas, VI Note: Please use the following address when mailing overnight parcels to the VIBNL. 9150 Estate Thomas, Suite 206 St. Thomas, VI 00802 GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS -----O----- DEPARTMENT OF HEALTH Virgin Islands Board of Nurse Licensure P.O. Box 304247 St. Thomas, Virgin Islands 00803 Tel: (340) 249 0684 APPLICATION FOR REGISTRATION RENEWAL TO PRACTICE AS A LICENSED PRACTICAL NURSE /REGISTERED NURSE/ ADVANCED PRACTICE REGISTERED NURSE VI License # _______ LPN RN APRN Social Security # ___-___-____ Marital Status: S M D W Email_____________________ Employment Status (Please Circle One) 1. Full Time 2.Part Time 3. Unemployed Employment - Location 1. In Territory ___________________ (Island) 2. Out of Territory _______________ (State) □ Please check this box if your information has changed since your last renewal. Submit proof of name change to complete your application if applicable. Name __________________ ___________ ___ ___________ Last Name First Name Middle Initial Maiden Name Mailing Address _______________ _____________ _____ _______ Street or PO Box City State ZIP or Postal Code Tel #: Home (___) ___-____Cell (___) ___-_____ Work (___) ___-____ Highest Level of Education (if changed from last renewal) __________________________ Employment – Principal Field Employment - Current Position (Please Circle One) (Please Circle One) 1. Hospital 7. Occupational Health 1. Administrator/ Assistant Administrator 2. Long Term Care 8. Medical/Dental Office 2. Chairperson/Vice-chairperson 3. School of Nursing 9. Community Health 3. Professor/Instructor 4. Private Duty/Home Health 10. Telehealth 4. Supervisor/Clinical Care Coordinator 5. School Nurse 11. Self-Employed 5. Head Nurse/Assistant Head Nurse 6. Hospice Care 12. Other__________ 6. Advanced Practice Registered Nurse 7. Registered Nurse 8. Licensed Practical Nurse 9. Other _________________ Have there been any complaints or disciplinary actions taken or pending against your professional nursing or occupational license, registration, or certification? Yes ( ) No ( ) If Yes, Where ________________________________ License #________________ Please attach explanation and supporting documents. Disclosure is required by submission of a separate document, of ALL misdemeanors, felonies, plea agreements (even if adjudication was withheld), and any actions taken or initiated against a professional or occupational license, registration, or certification and/or any substance use disorder within the last five (5) years. FAILURE TO DISCLOSE INFORMATION WILL RESULT IN DENIAL OF LICENSE RENEWAL My signature on this application certifies to the best of my knowledge and belief that all the information I have provided on this form and in any accompanying document(s) is true, accurate and complete. ________________________ ___/ ___/ ___ SIGNATURE DATE Employers, please complete the following: My signature confirms that the above licensee worked at least 320 hours within the last biennium as an APRN / RN / LPN (Circle One) Please provide supporting documentation for the reason employee did not work at least 320 hours within the last biennium. Renewal Fees: APRN $150.00 RN $125.00 LPN $100.00 Inactive Fee: $15.00 Lapsed Fees: Active Status $200.00 Inactive Status $30.00 Name of Facility/Organization: ____________________________________________________ Address of Facility: ______________________________________________________________ Period of Employment: ________________________________ Tel.# _____________________ Did the position require the employee to hold a current APRN/RN/LPN license? ___Yes ___No Verified by _________________________________________________ Title: _______________________ Signature of Supervisor/Clinical Care Coordinator, Human Resources Manager, Nurse Recruiter __________________________________________ Date:____ / ____ / ____ (PRINT NAME) Rev.6.2019 OFFICE USE Paid ____________________ Renew Registration______________ Do Not Renew _____________ Board Review ______________ GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HEALTH Virgin Islands Board of Nurse Licensure P.O. Box 304247 St. Thomas, Virgin Islands 00803 Tel: (340) 249-0684 ext. 5682/5683 CONTINUING EDUCATION RECORD Name: ___________________ ________________ ____ ______________ VI License #: ___________________ Last First Middle Initial Maiden APRN RN LPN E-Mail: __________________________________ Tel #: (___) ___-____ (___) ___-_____ (___) ___-____ Cell Home Work In compliance with the Nurse Practice Act (#4666 Section 415 Title 3 – Virgin Islands Code Subchapter IV, Bill # 14-0094), the Virgin Islands Board of Nurse Licensure (VIBNL)requires documentation of continuing education completed within the previous biennium related to NURSING PRACTICE: The VIBNL recognizes these courses as follows: • Basic Cardiac Life Support (BCLS) = 3 contact hrs. • Advanced Cardiovascular Life Support (ACLS) -5 contact hrs. , Pediatric Advanced Life Support- 5 contact hrs., (PALS),- 5 contact hrs., Neonatal Advanced Life Support (NALS)- 5 contact hrs. • Any nursing or health-related college credits* completed within the previous biennium may be utilized using the following equation: number of course credits x length of course (in weeks). Example: 3 credits x 15 weeks = 45 CEUs *Copy of transcript must be submitted Certificates of Completion SHOULD NOT BE SUBMITTED with the renewal application. Random audits will be conducted and those licensees whose files are audited, will be required to produce hard copies of Certificates of Completion for all contact hours listed on the renewal form. Failure to produce Certificates of Completion may result in disciplinary action. NAME OF EDUCATIONAL OFFERING COMPLETE NAME OF ORGANIZATION/INSTRUCTOR CONDUCTING COURSE PROVIDER NUMBER LOCATION (ONLINE, LOCALLY, NATIONALLY) DATE(S) OF COMPLETION (MM/DD/YYYY) NUMBER OF CONTACT HOURS EARNED OFFICE USE ONLY Reviewed by:__________ Date:_________ Review Code: _____________ A=Approved D=Disapproved AU=Audited TOTAL NUMBER OF CONTACT HOURS I hereby affirm and declare that the above information is true, accurate, and complete and that any fraudulent entry will be cause for denial of renewal and may result in disciplinary action. __________________________________ _____________________ Signature Date GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES -----O----- DEPARTMENT OF HEALTH Virgin Islands Board of Nurse Licensure P.O. Box 304247 St. Thomas, Virgin Islands 00803 Temporary #: (340) 249-0684 ext. 5682/5683 AGREEMENT OF COLLABORATIVE RELATIONSHIP Between _________________________________, MD _______________________________, MSN, APRN This Agreement of Collaborative Relationship has been made and is now duly written between ___________________________, MD and _________________________, APRN as of this _____ day of ___________, 20_____. Said agreement which is being submitted as a required of the Virgin Islands Board of Nurse Licensure (VIBNL), shall show the intent for the following mutual collaborative responsibilities between the Advanced Practice Registered Nurse (APRN) and the Physician. 1. The Physician agrees to be available to the APRN for consultation collaboration and referral as necessary. 2. The APRN agrees to practice within the Scope of Practice as defined in the Rules and Regulations established by the VIBNL. 3. Both parties agree to maintain high ethical and professional standards. It is understood that any changes in this Agreement must be submitted to the VIBNL within 30 days of the change. Respectfully Submitted, Print Name of Physician Print Name of APRN Signature of Physician Signature of APRN Witness Date GOVERNMENT OFTHE UNITED STATES VIRGIN ISLANDS -----O----- DEPARTMENT OF HEALTH Virgin Islands Board of Nurse Licensure P.O. Box 304247 St. Thomas, Virgin Islands Temporary Telephone #: (340) 249-0684 ext. 5682/5683 PROFESSIONAL ACTIVITY FORM Use this form to document fulfillment of practice requirement as an ALTERNATIVE to meeting the stipulation of 320 hours of active nursing practice. Complete Section 1 and submit this form to the organization/agency/association where the volunteer professional activities were performed for validation. Completed form must be submitted with other renewal documents. Section 1 I, _______________________________ am complying with the competency requirements of my nursing registration to practice as  an Advanced Practice Registered Nurse,  a Registered Nurse, or  a Licensed Practical Nurse and hereby authorize the release of information as required on this form. Name: ________________________________ Social Security #:______________________ Mailing Address:_______________________________________________________________ E-mail: ________________________ Telephone:___________________________ Signature __________________________________ Date:_______________________ Section 2 EMPLOYER/ORGANIZATION/ASSOCIATION Please complete the information below: This is to verify that _______________________________________ performed ________ hours (Name of Nurse) (Number) of work/volunteer activity for ___________________________________________________ at (Organization) ____________________________________________________________________________________________. (Address) Description of work/volunteer activity ______________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. Start Date: Date of Completion: Verified by: Title/Position: Print Name Signature: Date: Rev. June 2021 COMPETENCIES 1. Continuing Education – Five (5) of fifteen required contact hours must be obtained throughseminars or a formalized continuing education offering (i.e.: professional association conferences,on-line courses, Board approved community-based offerings, university offerings). 2. Professional Activities – 15 hours of participation in a professional activity. a) Active participation as an officer, in a professional nursing or health-related organization. b) Author or contribute to an article, book, or publication related to nursing and health care. c) Develop and present a health-related educational offering to a professional or lay audience. d) Design and conduct a research study relating to nursing and health care. e) Volunteer or engage in community service related to nursing and health care. f) Provide full time, unpaid care and/or non-registry private duty nursing –– (friend or relative). g) Functioning in the role of Examiner, Proctor, and/or Rater for licensing and/or certification exams. h) Other professional activities pre-approved by the Board. Alternative Methods for Meeting Competency Requirements A nurse may meet continued competency requirements by providing the Board with documentation of one of the following: 1. Completion of a Board pre-approved refresher course consisting of both theory and clinical components that is at least 160 hours in length. 2. Attainment of a degree or documentation of successful completion (transcript) of two required courses of formal nursing education beyond basic educational requirements for the original license. 3. Successful completion of the National Council of State Boards of Nursing Licensing Examination (NCLEX/CAT) 4. Attainment of certification for specialty areas in nursing or demonstration of maintenance of specialty certification.