Petition for Order Modification Board of Nursing
Petitioner's Name: _
Petitioner's Mailing Address: _
Petitioner's E-Mail Address: _
Telephone Number: _
Attorney for Petitioner: _
Attorney's Mailing Address: _
Attorney's E-Mail Address: _
Telephone Number: _
The petitioner respectfully represents that for the following reasons, as substantiated by the attached documentation, the identified provisions of the attached disciplinary order cannot or should not continue to be imposed:
Note - You must enclose all documents necessary to prove your request including a copy of the original order. If any of the proof you are relying upon to show the need for order modification is the testimony of any individual, including yourself, you must enclose signed and notarized statements from every individual you intend to rely upon attesting, under oath, to the reasons why compliance is impossible or should not be required. No documentation or testimony other than that submitted will be considered in making an initial determination on, or a final order in response to, this petition.
Respectfully submitted this the_day of_, 20_
Petitioner's Signature
It is the intent of the Board that the subpoena power outlined herein shall be strictly proscribed. Such power shall not be used by the division or board investigators to seek other incriminating evidence against nurses when the division or board does not have a complaint or basis to pursue such an investigation. Thus, unless the division or its investigators have previously considered, discovered, or otherwise received a complaint from either the public or a governmental entity, then no subpoena as contemplated herein shall issue.
Mail or Deliver to: Executive Director, Tennessee Board of Nursing
227 French Landing, Suite 300 Heritage Place, MetroCenter
Nashville, TN 37243
Tenn. Comp. R. & Regs. 1000-01-.04
Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-217, 4-5-223, 4-5-312, 4-5-316, 4-5-317, 63-1-122, 63-1-144, 63-7-115, 63-7-116, and 63-7-207.