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    Validation of Education Form

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    ROCK
    This document is a Validation of APRN Education Form. It requires the candidate and program director to provide information about the candidate's advanced practice registered nurse (APRN) education program, including population and role, degree type, date of completion, clinical hours, accreditation, coursework, and a statement of understanding signed by the program director. The completed form validates the candidate's educational preparation for APRN certification and must be submitted to the American Nurses Credentialing Center.

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    Validation of Education Form

    Uploaded by

    ROCK
    129 views2 pages
    This document is a Validation of APRN Education Form. It requires the candidate and program director to provide information about the candidate's advanced practice registered nurse (APRN) education program, including population and role, degree type, date of completion, clinical hours, accreditation, coursework, and a statement of understanding signed by the program director. The completed form validates the candidate's educational preparation for APRN certification and must be submitted to the American Nurses Credentialing Center.

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    This document is a Validation of APRN Education Form. It requires the candidate and program director to provide information about the candidate's advanced practice registered nurse (APRN) education program, including population and role, degree type, date of completion, clinical hours, accreditation, coursework, and a statement of understanding signed by the program director. The completed form validates the candidate's educational preparation for APRN certification and must be submitted to the American Nurses Credentialing Center.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    129 views2 pages

    Validation of Education Form

    Uploaded by

    ROCK
    This document is a Validation of APRN Education Form. It requires the candidate and program director to provide information about the candidate's advanced practice registered nurse (APRN) education program, including population and role, degree type, date of completion, clinical hours, accreditation, coursework, and a statement of understanding signed by the program director. The completed form validates the candidate's educational preparation for APRN certification and must be submitted to the American Nurses Credentialing Center.

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    C E R T I F I C AT I O N

    Validation of APRN
    Education Form

    CANDIDATE Please fill in the Candidate Information Section of this form and
    give it to the Program Director to complete the balance of the form and sign.
    PROGRAM DIRECTOR When entering course numbers, please include the
    actual courses the Candidate completed. Please fill in all required fields and
    submit as follows:
    • Hard copy, signed, and returned to the candidate to be forwarded to ANCC
    • OR, signed electronically and e-mailed to APRNValidation@ana.org
    • OR, mailed to:
    American Nurses Credentialing Center (ANCC)
    Attn: Certification Registration
    8515 Georgia Avenue, Suite 400
    Silver Spring, MD 20910

    CPM-FRM-51 | Validation of APRN Education Form | November, 2018


    Validation of APRN Education Form

    CANDIDATE INFORMATION

    Applicant Last Name First Name MI

    Other Legal Names Used Email

    Address City State Zip/Postal

    PROGRAM INFORMATION

    Name of University City State

    Program Director Name Program Director Phone Number Program Director Email

    CANDIDATE EDUCATIONAL PREPARATION

    Population and Role of Program Completed (e.g., Family Nurse Practitioner, Adult-Gerontology CNS)

    Degree Type: Master’s DNP Post-Graduate*


    *If a Post-Graduate program, school must document and submit credit granted for prior courses/clinical hours accepted from previous
    program(s) via Gap Analysis and/or signed statement on school letterhead.

    Date of (Anticipated) Completion Number of Faculty-Supervised Direct, Patient Care Clinical Hours

    Accreditation of Program Completed (at time of clinician’s graduation): ACEN CCNE CNEA Exp Date: _________

    Dual Program? Yes* No


    *If yes, specify the role and populations of the programs in the box above and attach a detailed description of the content and
    clinical hours for each role and population. Use letterhead and sign the attachment.

    Health Promotion/Disease Prevention Content: Yes No / Differential Diagnosis/Disease Management Content: Yes No

    Course Number Title


    Advanced Physical/Health Assessment

    Advanced Pathophysiology

    Advanced Pharmacology

    For PMHNP clinicians ONLY


    Content in at least 2 psychotherapeutic treatment modalities Yes No

    STATEMENT OF UNDERSTANDING
    I, ___________________________________________, ____________________________________________ of the
    insert name insert title

    _____________________________________________________________, attest that I am duly authorized by the above school to


    insert program name
    confirm the information provided in this Validation of APRN Education Form (“Form”) to be true, accurate, and complete, and reflect
    only the coursework and clinical hours actually completed by the Candidate for Certification identified above (the “Candidate”).
    (Forms received without a signature incur a delay in processing, which will cause a delay in the review of the Candidate’s application
    and ability to take a certification examination.)

    Required Program Director Signature Print Name Date


    ANCC reserves the right to request a more detailed accounting of coursework/program completed. ANCC reserves the right to
    contact the faculty with questions upon review of transcript(s), etc.

    CPM-FRM-51 | Validation of APRN Education Form | November, 2018

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