LSBN Clinical Disclosure Form - Louisiana State Board of Nursing 2026

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The document is a Clinical Nursing Student Disclosure Form from the Louisiana State Board of Nursing, intended for nursing students to report any incidents that occur after their initial approval. It outlines various reasons for disclosure, including legal issues, license restrictions, military discharge status, and medical conditions affecting nursing practice. The form requires detailed statements and certified documentation related to the disclosed incidents. It is specifically for students currently enrolled in a clinical nursing course.

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Click ‘Get Form’ to open the LSBN Clinical Disclosure Form in the editor.
Begin by filling out your personal information in the 'Clinical Student Information' section. Include your name, address, phone number, date of birth, email address, and student number.
In the 'Name and Type of Nursing Program' field, specify your nursing program details clearly.
For the 'Reason for Disclosure', check all applicable boxes that pertain to your situation. Be thorough and honest in your disclosures.
Sign and date the form at the bottom where indicated. Ensure that both you and your Dean/Director sign it as required.
Attach any required documentation as specified in each disclosure category to support your claims.

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2015	4.8 Satisfied (256 Votes)

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