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Frequently Asked Questions - Nursing Practice

Workplace and Employment — General Information

What is the BON Proposed Nursing Work Hours Position Statement?

BON Proposed Nursing Work Hours Position Statement. The Texas Board of Nursing's (BON) Nursing Practice Advisory Committee (NPAC) initiated an online survey concerning nursing work hours which was conducted on the BON web site. The survey was developed in response to research...Toggle Expand/Collapse Text

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Mandatory Overtime/Consecutive Shifts

Can an employer require a nurse to work longer than scheduled, or to work overtime?

How many consecutive hours or shifts can a nurse work?

The Texas Board of Nursing (BON) does not have authority over work-place issues, such as schedules or number of hours worked, either consecutively, in a given time period or "on-call". In 2009, during the 81st Legislative Session, SB 476 made changes to the Nursing Practice Act (NPA) and the Health & Safety Code. SB 476 applies to hospitals and nurses working in hospital settings only. Toggle Expand/Collapse Text

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Staffing Ratios

Is there a law regarding how many patients (nurse: patient ratio) a nurse can be assigned to care for in Texas?

The Texas Board of Nursing (BON) has no authority over workplace or employment issues, such as staffing ratios. The Nursing Practice Act (NPA) Nursing Practice Act  and Board Rules are written broadly to apply to nursing practice by all nurses (LVNs, RNs, & APRNs) in any practice setting. Board Rule 217.11, Standards of Nursing Practice provides the minimum standards nurses must meet in accepting any assignment, including floating, working with inadequate staffing and other practice situations, specifically: Toggle Expand/Collapse Text

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Floating to Unfamiliar Practice Settings

Question: I Nurses in my facility are often required to float from their home unit to other care units where they do not have clinical competence and/or clinical experience. What is the duty of the nurse  when it comes to floating to different clinical units (adults, pediatric, ER, etc.)?.  Can a nurse invoke Safe Harbor? If so, how do nurses invoke Safe Harbor?

Answer: The Nursing Practice Act (NPA) Nursing Practice Act and Board rules Board Rules are written broadly to apply to nursing practice in any setting.  Although the Board of Nursing (BON) has no authority over workplace policies, such as floating or staffing ratios, nurse staffing was addressed in SB 476 during the 81st Legislative Session in 2009. Toggle Expand/Collapse Text

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When Does a Nurse's Duty to a Patient Begin and End?

Employment versus Licensure

There is no routine answer to the question, “When does the nurse’s duty to a patient begin?” A nurse's duty is not defined by any single event such as clocking in, or taking report. From a Board of Nursing standpoint, the focus is on the relationship and responsibility of the nurse to the patient(s), not to the nurse's employer or employment.Toggle Expand/Collapse Text

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Safe Harbor Peer Review

What is Safe Harbor Peer Review?
Safe Harbor is a process that protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, and licensure sanction when a nurse makes a good faith request for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation of the NPA or Board rules. Toggle Expand/Collapse Text

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A Nurse's Duty Not Limited to Assignment:

All nurses, regardless of practice setting, position, title or role, are required to adhere to the NPA and other statutes, as well as the Board Rules. Two of the main rules that relate to nursing practice are Texas Administrative Code, Rule §217.11 Standards of Nursing Practice,...Toggle Expand/Collapse Text

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Decision Making for Determining Nursing Scope of Practice.

Where can I find a list of tasks that LVNs and/or RNs can or cannot do in the State of Texas?

The Nursing Practice Act (NPA) and Board Rules are written broadly so that they can apply to nursing practice in any setting. As such, the BON does not provide lists of tasks or step-by-step procedures of how certain tasks are to be carried out by the nurse. Toggle Expand/Collapse Text

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Nurses Have a Duty to Report Confidential Health Information

Do nurses have a duty to report confidential health information to administrators, law enforcement of to a patient's family?

Nurses have a duty to report patient information, including mental health information, to members of law enforcement, a patient's family and others when a patient is a serious danger to himself or others. Toggle Expand/Collapse Text

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Nurse Admitted As Patient Under the Influence

I currently work in an ICU. I had an opportunity to care for a patient/nurse (who was a nurse at another facility) who overdosed. She was transferred, when stable, to a treatment center by court order. I was told we cannot report her to the board due to HIPAA. My question is, "How do we plan to handle this type of incident in the future?" "Will there be any specific changes made to address problems like this in the future?" I understand with the renewal of our license we must answer the question of treatment for use of "alcohol or any other drug." But if there is no report of her being in the hospital for treatment, due to HIPAA, it's possible that she may not answer the question truthfully. Can you please help with these questions. I appreciate your time.

Whether a nurse is admitted for an overdose of a substance, or admitted secondary to some type of accident related to being under the influence of any mind-altering substance, the answer would remain the same....Toggle Expand/Collapse Text

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CPR - A Nurse's Duty to Initiate

Is current CPR certification a licensure requirement for nurses?

No. The Texas Board of Nursing (Board or BON) does not require CPR for licensure renewal; however, employers may have specific requirements for maintaining current CPR status as a condition of employment.Toggle Expand/Collapse Text


GNs, GVNs, and Newly Licensed Nurses Practicing in Home Health Settings

I will be graduating from a vocational nurse training program in a few months, and am beginning to seek out employment options once I graduate. I am attracted to the area of home health nursing, and I wondered if LVNs can work in home health settings? (Note: The same answer applies to graduates of registered nurse training programs).

As a newly graduated LVN (or RN), I am interested in home health nursing.  Should I work in this environment as a new nurse?

When you graduate from your vocational training program or your professional nursing program, you will likely be eligible for a temporary permit to practice as a Graduate Vocational Nurse (GVN) or Graduate Nurse (GN).  Board Rule §217.3 prohibits GVNs and GNs from working in "independent practice settings", which includes home health settings.Toggle Expand/Collapse Text

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Practice Recommendations for Newly Licensed Nurses

Does the Board of Nursing (BON) have any recommendations for newly licensed LVNs or RNs as they begin their nursing practice?

The newly licensed nurse is in a transitional process and as a novice practitioner, the new LVN or RN is inexperienced and not fully integrated into his/her nursing role and setting. Based on this belief, the Board provides the following guidance to newly licensed LVNs or RNs: Toggle Expand/Collapse Text

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Regarding Position Statements 15.27, The LVN Scope of Practice and 15.28, The RN Scope of Practice

Position Statements 15.27 and 15.28 state that it is the LVN's responsibility to ensure appropriate supervision.  What is appropriate supervision?

Each LVN is required to ensure that he or she has the appropriate supervisor prior to accepting an assignment, a position, or employment. The Nursing Practice Act (NPA) Section 301.353 states that "the practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist." Rule 217.11, Standards of Nursing Practice, subsection (2) further clarifies that “the licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity."
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FAQ - LVNs Performing Initial Assessments

Can an LVN perform an “initial” assessment?

Board Rule 217.11, Standards of Nursing Practice, refers to focused assessments performed by LVNs [Board Rule 217.11(2)(A)] and comprehensive assessments performed by RNs [Board Rule 217.11(3)(A)]. Toggle Expand/Collapse Text

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LVNs and Nursing Care Plans

Can an LVN initiate/develop the nursing care plan?

LVNs may not initiate care plans; however, they may contribute to the planning and implementation of the nursing care plan.  Only the RN may develop the initial nursing care plan and make nursing diagnoses [Board Rule 217.11(3)(A)(ii) & (iii)]. Toggle Expand/Collapse Text

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LVNs Performing Triage/Telephonic Nursing/Being On-Call

Can LVNs in any practice setting be "on-call" to deal with after-hours issues?

Can an LVN perform "triage" duties (either telephone triage such as for home health or on-site such as an Emergency Room)?

Triage is defined as the sorting of patients and prioritizing of care based on the degree of urgency and complexity of patient conditions. Telephone triage is the practice of performing a verbal interview and making a telephonic assessment with regard to the health status of the caller. As the caller may not accurately describe symptoms, and/or may not accurately perceive or communicate the urgency of the situation or condition prompting the call, nurses who perform these functions must have specific educational preparation, as the consequences of inadequate triage can be devastating.1 Toggle Expand/Collapse Text

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LVNs "Supervision of Practice"

Describe what "supervision of practice" means in relation to an LVN functioning with a directed scope of practice “under the supervision of. . . .”

The LVN’s scope of practice requires that his or her nursing practice be directed by an appropriately licensed supervisor, e.g. registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist or dentist [Nursing Practice Act (NPA) Sections 301.002(5), 301.353 and Board Rule 217.11(2)]. Toggle Expand/Collapse Text

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Nurse's Role with the Emergency Medical Treatment & Labor Act: Performance of Medical Screening Exams

Background Information:

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a medical screening examination to each person presenting to the emergency department. Toggle Expand/Collapse Text


Seasonal Influenza and other Vaccinations

What are the requirements for a nurse to give flu injections?

Although the laws regarding immunizations are not within the BON's authority, an Attorney General opinion in 1981 (MW-318) determined immunizations are preventative, thus no medical diagnosis is required or made when a person receives an immunization. Board staff recommends that a facility have standing physician delegation orders that guide the nurse when to give pneumococcal or influenza vaccines. Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders, references the Texas Medical Board rules applicable to these types of orders, and provides guidance to nurses and employers on important components to include in standing delegation orders.Toggle Expand/Collapse Text

Role of the School Nurse With Unlicensed Diabetes Care Assistants (UDCAs) (HB984)

What is the BON' recommendation?

BON Position Statement 15.13, Role of LVNs and RNs as School Nurses, recommends that the school nurse be an RN, but does not absolutely preclude an LVN with appropriate...Toggle Expand/Collapse Text

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Can an LVN be a school nurse? Can an LVN train Unlicensed Diabetes Care Assistants (UDCAs) or serve in other roles (consultative relationship, administratively responsible)?

The BON does not preclude LVNs from being employed in school settings; however, the BON has no jurisdiction over employment practices or facility policies.  The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nursed, physician’s assistant, physician, podiatrist, or dentist (Board Rule 217.11(2).  Additionally, the LVN contributes to the development and implementation of teaching plans for patients and their families with common health problems and well-defined health needs.  LVNs may teach from a developed education plan as well as contribute to its development.

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Who is responsible for determining which school employees will be trained as Unlicensed Diabetes Care Assistants (UDCAs)?

NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...Toggle Expand/Collapse Text

Who is responsible for training the Unlicensed Diabetes Care Assistants (UDCAs) in schools? Can a healthcare provider with expertise in diabetic care be contracted to do all of the training for an individual school or a school district?

NThe training of Unlicensed Diabetes Care Assistants in Texas public schools is not within the BON's jurisdiction...Toggle Expand/Collapse Text

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 A school nurse is assigned to 3 different elementary schools within one district and rotates between the schools. The schools’ principles assign who will be trained as Unlicensed Diabetes Care Assistants (UDCAs). The principals also assume administrative responsibility for these staff whether they are functioning within their job descriptions or in the "extra" role of UDCA. Working with the principals at all 3 schools, the RN coordinates training of all UDCAs through another RN with expertise in all aspects of the care of children with diabetes.

Given the situation, as described above, what is the role of the RN with the Unlicensed Diabetes Care Assistants (UDCAs) from a BON standpoint?

According to the Health & Safety Code, Chapter 168, if a school nurse is assigned to a campus, the school nurse shall coordinate the training of school employees acting as unlicensed diabetes care assistants.

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How does the RN provide adequate communication and information to the UDCAs at each school related to the diabetic care needs of each child?

Congruent with the diabetes management and treatment plan and the individualized health plan for each child with diabetes, the RN can develop information sheets with emergency contact numbers, reportable conditions, and how to intervene in a number of possible emergency situations that could occur with each child.  Health and Safety Code, Section 168 and school policy mandate that this information be given to any school employee transporting a child or supervising a child during an off-campus activity.  The school principal and the school nurse, if a school nurse is assigned to the school, shall develop a student’s individualized health plan in collaboration with the student’s parent or guardian and, to the extent practicable, the physician responsible for the student’s diabetes treatment and one or more of the student’s teachers (Health and Safety Code Sec 168.003.) The Nursing Practice Act Sec.301.002(5) (NPA) defines the licensed vocational nurse (LVN) scope of practice as a directed scope of nursing practice and specifically states that LVNs participate in the development and modification of the nursing care plan, whereas the registered nurse (RN) is responsible for the development of the nursing care plan. The LVN may assist with the development of the IHP but is not permitted to write it independently.

Can the LVN develop the Individualized Health Plan (IHP)?
No. This would be in violation of, Texas Health and Safety Code §168.003 that defines the IHP as a "coordinated plan of care" developed by the principal and the school nurse (RN) in collaboration with the student’s parent/guardian and the student’s physician, if possible. Developing or initiating a student’s IHP would also be beyond the LVN’s scope of practice as defined by the BON in Rule 217.11(2)(A).

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Health and Safety Code §168.008 mandates schools to permit and encourage students' abilities to engage in self-care. Occasionally, used supplies, such as insulin syringes or blood-stained gauze, may not be disposed of properly, exposing other children to potentially hazardous bodily fluids/blood that could carry HIV or Hepatitis.  Does HB984 mandate that a child always be permitted to engage in the self-management of diabetes anywhere on the campus, regardless of the health threat posed on other students if a given student isn't capable of disposing of used supplies and cleaning the testing area in a responsible manner? Must a student who is not capable, either by age, maturity or both, of appropriately maintaining supplies and equipment (not losing his/her glucometer, leaving used supplies where others could be exposed to blood, used sharps, etc.) be permitted to self-manage?

The Standards of Nursing Practice (Rule 217.11) require all nurses to prevent exposure of clients (students) to infectious pathogens and communicable conditions. The language in ...Toggle Expand/Collapse Text

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Does the LVN have to report signs and symptoms or changes in the student's health status to the school nurse (RN)?

LVNs and RNs are responsible for the assignments that they make or accept, and for complying with the NPA and Rules as outlined in Rule 217.11, Standards of Nursing Practice...Toggle Expand/Collapse Text

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What if the principal refuses to act on a school nurse’s report that the Unlicensed Diabetes Care Assistant (UDCA) is unable or unwilling to carry out applicable duties?

The BON has no jurisdiction over employment issues; however, the nurse should consider reporting up the chain of command, or if necessary, reporting to the Texas Education Agency (TEA), http://www.tea.state.tx.us/. The nurse always has a duty to provide a safe environment for the client, which may include advocating for the client through other channels to prevent harm. (Position Statement 15.14, Duty of Nurse in Any Practice Setting.) Failure to do so may result in the reporting of the nurse to the BON with a subsequent investigation and possible sanctions on the nurse’s license for failing to intervene in the client’s best interest. The BON staff encourage nurses to utilize the chain of command within their employment setting. If unable to reach a resolution, then ultimately the nurse may have to choose between changing employment settings or risking action on his/her nursing license.

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Is it within the RN’s scope of practice to train the Unlicensed Diabetes Care Assistant (UDCA)?

Though all RNs receive both knowledge and skills training in care of clients with diabetes across the life span, this does not necessarily mean that every RN is capable of effectively training a UDCA...Toggle Expand/Collapse Text

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Can a nurse train Unlicensed Diabetes Care Assistants (UDCAs), teachers, and other school personnel in the administration of glucagon?

While the BON has no jurisdiction over school district policies, nurses do have the obligation to promote a safe environment for students and staff [Rule 217.11(1) (B)] and to institute appropriate nursing interventions to stabilize a client's condition and prevent complications [Rule 217.11 (1) (M)]. Glucagon is prescribed to thousands of students with diabetes. Both students and their parents or guardians are instructed by providers and pharmacists on administration of glucagon should a hypoglycemic reaction occur.

Chapter 224 becomes applicable in the ISD setting when acute health conditions arise and patients become unstable or unpredictable, i.e., an emergency situation.  Section 224.6, General Criteria for Delegation, outlines the standards that must be met before an RN can delegate nursing tasks to unlicensed persons.  In the ISD setting even during an emergency situation, the RN cannot delegate tasks that require unlicensed persons to exercise professional nursing judgment; but, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation.  This forms the basis for the Frequently Asked Question from the Board’s  Delegation Resource Packet online entitled Medications or Procedures in an Emergency Situation, which might provide more clarification.  Each nurse will need to exercise nursing judgment to decide when it is appropriate and safe to delegate in emergency situations, remembering the supervision requirements of delegation.

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Other Resources

Acknowledgments

The BON wishes to thank Anita Wheeler, MSN, RN, Texas School Health Network Administrator and School Nurse Consultant at the Texas Department of State Health Services, and Susan Young, MSN, RN, former Nurse Consultant for the Diabetes Program at the Texas Department of State Health Services, for their assistance in the development of this document.

Revised 2017

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Off Label Use of Medication

May I administer a medication if the use is considered to be off label?

The Nursing Practice Act or NPA (Texas Occupations Code, Chapter 301) and Board Rules are written broadly so they can be applied by every nurse to all of the many different practice settings and specialty areas in nursing across Texas. The BON does not have a list of tasks that nurses can perform because each nurse has a different background, knowledge and level of competence. Determinations of a nurse's scope of practice are often complex and it is up to the individual nurse to utilize sound professional judgment in accepting any given assignment and/or performing any given procedure.

Off label use indicates that the medication is being used in a way not specified in the FDA’s approved packaging label, or insert. All prescription drugs marketed in the U.S. have an FDA-approved label.  Toggle Expand/Collapse Text

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Nurses Performing Radiologic Procedures

Are there rules regarding nurses performing radiologic procedures?

Yes, BON Rule 217.14, Registered Nurses Performing Radiologic Procedures.Toggle Expand/Collapse Text

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RN Pronouncement of Death

Texas Senate Bill 823 (1991) amended Section 671.001 of the Texas Health and Safety Code and gave RNs the legal authority to assess a patient/client and make a determination of death, unless the pronouncement is clearly prohibited under the Health and Safety Code (such as when an inquest is required). The bill specifically requires the RNs employing agency/facility to have written policies jointly developed and approved by the nursing and medical staff to direct the practice. Toggle Expand/Collapse Text

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BON Rules and Regulations Relating to Telenursing/Telehealth

What are the Texas Board of Nursing (BON) Rules and Regulations Relating to Telenursing/Telehealth?

Telenursing involves nursing practice via any electronic means such as telephone or computer. Examples of telenursing practice may include (but are not limited to) teaching, consulting, triaging, advising, or providing direct services.
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Forensic Evidence Collection

Who is required to have forensic evidence collection continuing education?

Pursuant to the Health and Safety Code §323.004 and §323.0045, a nurse licensed in Texas or holding a privilege to practice in Texas, including an APRN, who performs a forensic examination on a sexual assault survivor must have basic forensic evidence collection training or the equivalent education prior to performing the examination.  This is a onetime requirement. Toggle Expand/Collapse Text

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Co-signature on Documentation

When a Graduate Nurse (GN) or Graduate Vocational Nurse (GVN) has completed all requirements for the nursing program attended, and has received permission to test for nursing boards, must the preceptor co-sign the nursing assessment, medication administration, and other records for patients assigned to the GN/GVN?

Besides obtaining approval to sit for the NCLEX, a student who has successfully completed a nursing program must also hold a current valid temporary permit from the Board to practice as a GN or GVN in the state of Texas. Toggle Expand/Collapse Text

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Co-signature on LVN Actions/Documentation

Must an RN sign behind or "co-sign" nursing actions performed by an LVN?

In general, BON staff does not recommend a nurse co-sign anything unless he/she has directly witnessed an act (such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings. Toggle Expand/Collapse Text

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FAQ - Differentiating the Role of the Texas Board of Nursing from the Role of Professional Nursing Associations

What is the difference between the Texas Board of Nursing and professional nursing organizations?

Although the Texas Board of Nursing and professional nursing associations are both involved in the arena of nursing, nursing associations serve a different purpose and provide different services to their nursing membership and the public. Toggle Expand/Collapse Text

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FAQ – Doctoral Degrees in Nursing and Using the Title “Doctor”

Question: I am a nurse in Texas and recently graduated with a Doctor of Nursing Practice (DNP). Can I use the title “Doctor” when I work with patients and other healthcare providers?

Answer:

One of the hallmarks of nursing is the approach to lifelong learning. As nurses earn advanced degrees, the number of nurses earning doctoral degrees is increasing....Toggle Expand/Collapse Text

 

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For more information on these and other topics, use the search field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.