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Person submitting report

Name of Licensee/Registrant about whom you are reporting

Please describe the conduct about which you are reporting. It is important to be as specific as is reasonably possible. If you are in possession of medical records or other documents which support your allegations, you may provide them to the board by uploading them as indicated below, or by mailing them to the board at ND Board of Nursing, 919 S 7th Street, Suite 504, Bismarck, ND 58504. Note: the character limit for this field is 4000 characters.

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Note: The person named in the allegation may be given a copy of the Potential Violation Report.