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    Record of Nursing Program: This Section To Be Completed by Applicant (Items 1-6) - Print or Type (Do Not Use Pencil)

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    Kat Alinea Aragoza
    This document contains a record of nursing program form to be completed by applicants and nursing program directors. The form requests information such as the applicant's name, address, birthdate, and contact details. It also asks the program director to provide details of the nursing program including dates attended, total hours/credits completed, grades received, and whether the program was accredited. The director must sign the form to certify the information is true and correct under penalty of perjury.

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    Record of Nursing Program: This Section To Be Completed by Applicant (Items 1-6) - Print or Type (Do Not Use Pencil)

    Uploaded by

    Kat Alinea Aragoza
    15 views2 pages
    This document contains a record of nursing program form to be completed by applicants and nursing program directors. The form requests information such as the applicant's name, address, birthdate, and contact details. It also asks the program director to provide details of the nursing program including dates attended, total hours/credits completed, grades received, and whether the program was accredited. The director must sign the form to certify the information is true and correct under penalty of perjury.

    Original Title

    55a-2

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    This document contains a record of nursing program form to be completed by applicants and nursing program directors. The form requests information such as the applicant's name, address, birthdate, and contact details. It also asks the program director to provide details of the nursing program including dates attended, total hours/credits completed, grades received, and whether the program was accredited. The director must sign the form to certify the information is true and correct under penalty of perjury.

    Copyright:

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

    Record of Nursing Program: This Section To Be Completed by Applicant (Items 1-6) - Print or Type (Do Not Use Pencil)

    Uploaded by

    Kat Alinea Aragoza
    This document contains a record of nursing program form to be completed by applicants and nursing program directors. The form requests information such as the applicant's name, address, birthdate, and contact details. It also asks the program director to provide details of the nursing program including dates attended, total hours/credits completed, grades received, and whether the program was accredited. The director must sign the form to certify the information is true and correct under penalty of perjury.

    Copyright:

    © All Rights Reserved
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    of 2

    BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

    Board of Vocational Nursing and Psychiatric Technicians


    2535 Capitol Oaks Drive Suite 205, Sacramento, CA 95833-2945
    Phone 916-263-7800 Fax 916-263-7855 www.bvnpt.ca.gov

    RECORD OF NURSING PROGRAM


    The applicant should complete the first section of this form and provide it to the Director of the nursing program. The Director
    of the nursing program should complete the information in the second section and return it to the above address.

    THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6). PRINT OR TYPE (DO NOT USE PENCIL)

    1. NAME (LAST) (FIRST) (MIDDLE)

    2. ADDRESS (STREET OR BOX NUMBER) (APT. NO)

    3. CITY STATE ZIP

    4. BIRTHDATE (Month/Day/Year) 5. SOCIAL SECURITY NUMBER* 6. TELEPHONE NUMBERS


    BUSINESS
    HOME

    THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL, PRACTICAL OR REGISTERED NURSING.


    PRINT OR TYPE (DO NOT USE PENCIL)

    7. NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING: CITY STATE

    ______________________________________________________________________ ______________________________________________________

    DATE PROGRAM STARTED: ______________DATE PROGRAM COMPLETED: ______________ OR DATE VERIFIED HOURS WERE COMPLETED________________

    WAS PROGRAM “ACCREDITED” WHEN HOURS WERE COMPLETED? □ YES □ NO


    8. NAME OF SCHOOL OF REGISTERED NURSING: CITY STATE

    _______________________________________________________________________ _______________________________________________________

    DATE PROGRAM STARTED: _____________ DATE PROGRAM COMPLETED: _______________ OR DATE VERIFIED HOURS WERE COMPLETED________________

    WAS PROGRAM “ACCREDITED” WHEN HOURS WERE COMPLETED? □YES □NO


    9. COMPLETION OF THE TWELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOWS:

    □ PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL

    □ PASSED THE “GED” TEST AT THE 12TH GRADE LEVEL

    10. A. TOTAL NUMBER OF THEORY/CLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM:

    THEORY: __________HOURS CLINICAL: __________HOURS

    B. TOTAL NUMBER OF THEORY/CLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR “PREVIOUS EDUCATION”:

    THEORY: __________HOURS CLINICAL: __________HOURS

    C. COMPLETE THE SECOND PAGE OF THIS FORM IN FULL. THIS IS A MANDATORY REQUIREMENT.
    11. I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.

    SIGNATURE OF PROGRAM DIRECTOR: _____________________________________________

    (SCHOOL SEAL) PRINT PROGRAM DIRECTOR’S NAME:_____________________________________________

    DATE: ________________________________________________________________________

    * SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT –


    Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of
    your social security number. Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for
    family support in accordance with Section 17520 of the Family Code, or for verification of licensure or examination status by a licensing or examination entity which utilizes a
    national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, your application for initial license will not be
    processed and you will be reported to the Franchise Tax Board.

    55A-2 (2/08)
    THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL

    1. NAME OF SCHOOL OF NURSING: 2. CITY 3. STATE AND COUNTRY

    ___________________________________________________________

    CHECK ONE:

    □ VOCATIONAL/PRACTICAL NURSING PROGRAM

    □ REGISTERED NURSING PROGRAM

    4. DATE PROGRAM STARTED: ____________________________________ 5. DATE VERIFIED HOURS WERE COMPLETED: ____________________________

    (MONTH/DAY/YEAR) (MONTH/DAY/YEAR)

    HOURS/UNITS OF CREDIT
    6. SUBJECT ACTUAL HOURS/UNITS COMPLETED CHECK HERE GRADE RECEIVED GRANTED FOR PREVIOUS
    LEARNING
    IF SUBJECT IS
    THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
    INTEGRATED

    ANATOMY & PHYSIOLOGY N/A N/A N/A

    NUTRITION N/A N/A N/A

    PHARMACOLOGY N/A N/A N/A

    PSYCHOLOGY N/A N/A N/A

    NORMAL GROWTH & N/A N/A N/A


    DEVELOPMENT

    NURSING FUNDAMENTALS

    NURSING PROCESS

    MEDICAL SURGICAL NURSING

    COMMUNICABLE DISEASES

    MATERNITY NURSING

    PEDIATRIC NURSING

    GERONTOLOGICAL NURSING

    REHABILITATION NURSING

    LEADERSHIP N/A N/A N/A

    SUPERVISION N/A N/A N/A

    COMMUNICATION N/A N/A N/A

    PATIENT EDUCATION N/A N/A N/A

    ETHICS & UNETHICAL CONDUCT N/A N/A N/A

    CRITICAL THINKING N/A N/A N/A

    CULTURALLY CONGRUENT CARE

    END OF LIFE CARE

    TOTAL HOURS:

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