Follow the steps to successfully complete your form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employer or agency information in the designated fields. This includes the name and title of the person filing the report, agency name, address, city, state (MN), and zip code.
3. Provide contact information for the person filing the report, including work phone, home phone, email, and cell phone.
4. Fill out the details of the nurse being reported. If identical to the previous section, you can select 'Same as Above'. Otherwise, include their name, Minnesota license type and number, and employment details.
5. Detail the investigation and HR records with the relevant address, city, state, and zip code.
6. Complete the 'Practice Breakdown Information' section by entering the date of the event that prompted the report and indicating whether the incident was reported to another agency or law enforcement.
7. Provide information regarding previous discipline and outcomes related to the nurse’s actions, if applicable.
8. In the 'Statement of Complaint' section, describe the incident in detail. Include specific information such as dates, times, and locations. Attach additional pages and records if authorized.
9. Review and complete the notice of rights and attestation, ensuring that all statements are true and complete.
10. After verifying that all information is accurate, submit the form. You may have the option to save changes, download, print, or share the completed form.

Start filling out the MN NB-00921-00 online today to ensure your report is submitted correctly.