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Licensee Bank Form for COVID Assistance

The Licensee Bank form is used to request referrals from the Ohio Department of Health Licensee Bank during the COVID 19 outbreak.  The Licensee Bank includes Registered Nurses and Licensed Practical Nurses who are willing to be contacted by long-term care facilities in need of staffing assistance. 

If you are a licensed long-term care facility or residential care facility (Assisted Living), please download and complete the form and submit it to Bridgeteam@odh.ohio.gov and someone will contact you to complete the process.

Please select the 'Download' button to view the Licensee Bank Form.