VERIFICATION OF NURSE PRACTITIONER PROGRAM
State Board of Nursing 2601 North Third Street Harrisburg PA 17110
BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS
State Board of Nursing P O BOX 2649
Harrisburg PA 17105-2649
VERIFICATION OF NURSE PRACTITIONER PROGRAM
NAME:
Last:
OTHER NAME(S):
DATE OF BIRTH:
APPLICANT INFORMATION
First:
LAST 4 DIGITS OF SSN:
Middle:
ADDRESS:
CITY / STATE / ZIP:
TO BE COMPLETED BY THE NURSE PRACTITIONER PROGRAM DIRECTOR ONLY
NAME OF PROGRAM:
CITY / STATE: PRINT NAME OF DIRECTOR:
DIRECTOR'S PHONE NUMBER:
DIRECTOR'S EMAIL ADDRESS:
PROGRAM
DATE OF PROGRAM
DEGREE
SPECIALTY:
COMPLETION:
AWARDED:
Completed at least 45 hours / 3 credits of ADVANCED PHARMACOLOGY as part of the Nurse Practitioner Program. Yes ____ No ____
This Program included 2 hours of education in pain management or the identification of addiction. Yes ____ No ____
This Program included 2 hours of education in the practices of prescribing or dispensing of opioids. Yes ____ No ____
Advanced Pharmacology Completion Date: Month___________ Day__________ Year__________
*To be Completed by Out-of-State Nurse Practitioner Program Directors Only:*
*Total number of clinical hours completed:
*Length of Nurse Practitioner Program:
*Program Accreditation: CCNE _____ ACEN _____
*List Course Numbers for corresponding content:
* CONTENT TYPE
COURSE NUMBER
CONTENT TYPE
COURSE NUMBER
*Theoretical foundations of nursing practice:
*Professional role development:
*Human diversity/social issues:
*Health promotion / disease prevention:
*Health care policy / organization:
*Research:
*Advanced health / physical assessment:
*Ethics:
*Advanced physiology / pathophysiology:
*Advanced Pharmacology:
I verify that the above statements are true and correct as validated by my review of the applicant's school records. I verify that the information communicated on this form is true and correct to the best of my knowledge, information and belief. I understand that any false statement made is subject to the penalties of 18 Pa. C.S. ?4904, relating to unsworn falsification to authorities.
Original Signature of Director:
DATE: Month:
Day:
Year:
(School Seal)
MAIL DIRECTLY TO THE STATE BOARD OF NURSING IN AN OFFICIAL SCHOOL ENVELOPE TO P.O. BOX 2649, HARRISBURG, PA 17105-2649.
Revised 6-29-17
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