Ancc Certification Verification – Fill Out and Use This PDF

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 | May 2020­

Validation of APRN Education Form

CANDIDATE INFORMATION

*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.

Has the student completed all required APRN didactic courses/faculty supervised, direct patient care clinical hours, required for program

completion? Yes No

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.

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 • FOR FACULTY USE ONLY

I, ___________________________________________, ____________________________________________ of the

insert nameinsert 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.)

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 | May 2020