Indiana State Board of Nursing Candidate Submission Form

Indiana State Board of Nursing Candidate Submission Form

Indiana Code 25-23-1-3 instructs ISNA to recommend to the Governor a list of qualified nurses for appointment to the board when a vacancy arises. Additionally, the Office of the Governor retains interested candidate information in anticipation of Board of Nursing vacancies. The ISNA Board will review your submission refer your submission to the Office of the Governor or provide an explanation of disproval back to you for consideration. ISNA Membership is not required. The majority of data points below are required by the Governor's Office. If you have any questions, please reach out to Katie Feley, Katie@IndianaNurses.org
Scoring Rubric
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender:
Race:
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I have lived in Indiana for the past ____ years:
Political Affiliation
Registered to Vote
Have you had any disciplinary action taken against your professional licensure in Indiana or any other state?
If Yes, please explain:
Do you currently serve on other boards or commissions?
If Yes, please explain:
Have you ever been a registered as a lobbyist?
If Yes, please explain:
Have you individually, through your employer, or through any entity you own, had contract or business relationship with the State?
If Yes, please explain:
Do you have any ongoing litigation against you?
If Yes, please explain:
Which qualification(s) best describes your role?
The Coalition of Advanced Practice Nurses of Indiana (CAPNI) recommends CAPNI endorsement for APRN roles. If you are serving as an APRN, have you received endorsement to serve?
Why do you want to serve on the Indiana State Board of Nursing?
What motivates you to serve on the Indiana State Board of Nursing, and how does your background, professionalism, and commitment to equity prepare you for board responsibilities such as case review, policy oversight, and public‑interest service? (Commitment, Integrity & Fitness for Board Service)
Can you describe how your professional experience, ethical judgment, and understanding of the State Board of Nursing’s public‑protection role have prepared you for regulatory decision‑making? (Professional Qualifications, Judgment & Regulatory Understanding)
How do you approach high‑stakes, evidence‑based decisions, and how do you communicate and collaborate with diverse stakeholders while remaining objective and composed? (Critical Thinking, Communication, & Collaboration)
What skills or experiences will you bring to this seat?
My employer is aware of my interest in serving and understands and supports the role’s demands.
Please provide your resume or curriculum vitae.

Cancelof
I have read and understand the general expectations and time commitment. (Print or Print Preview to enlarge, if necessary)
Consent, Waiver, and Release: The undersigned authorizes the release to the Indiana Governor’s Office, its staff, agents, and representatives, of records and reports requested by the Governor’s Office in the performance of limited background checks on individuals who desire to serve on boards, commissions, councils, and other similar instrumentalities of the State of Indiana, such as criminal, driving, and disciplinary histories. The undersigned waives and releases the Indiana Governor’s Office, its staff, employees, agents, and representatives (including the Indiana State Police and any other agency or person providing such information to the Governor’s Office), from any claims and/or liabilities arising in connection with the furnishing and/or use of such information concerning the undersigned.
Should be Empty:

Indiana State Board of Nursing Candidate Submission Form

Scoring Rubric