Medical or Family Medical Waiver forms
Medical Waiver form 2024.pdf
Family Medical leave Exemption form 2024.pdf
If you have a lapsed license choose the blank work attestation based on the year your licensed lapsed/expired below. If it is not listed here then call the board 304-558-3572.
Blank work attestation July 1st 2024.pdf
Blank Work Attestation July 1st 2023.pdf
Blank Work Attestation July 1st 2022.pdf
Blank work attestation July 1st 2021.pdf
Blank Work Attestation July 1st 2020.pdf
Blank work attestation July 1st 2019.pdf
Blank Work Attestation July 1st 2018.pdf
Verification of employment (VOE) Forms: MUST have 400 hours every 2 years by even year: Your employer can fax it to the board 304-558-4367 or email lpn.board@wv.gov directly on their letterhead with the dates and hours on it. If the nurse uploads verification form it must be notarized.
90 DAY LIMITED MEMO 2024.pdf
VOE 90 day temp 2024.pdf
You will need to choose the verification of employment file below that correlates to your Audit Dates from message center or Dates you are reinstating
VOE 2024 to 2026 or 90 day limited.pdf
VOE 2022 to 2024 or 90 day temp 2024.07.18.pdf
VOE 2020 to 2022 or 90 day temp 2024.07.18.pdf
VOE 2018 to 2020 or 90 day temp 2024.07.18.pdf
VOE 2016 to 2018 or 90 day temp 2024.07.18.pdf
VOE 2014 to 2016 or 90 day temp 2024.07.18.pdf
VOE 2012 to 2014 or 90 day temp 2024.07.18.pdf
Background check form.pdf