ACNPC Endorsement Handbook (Adult) Acute Care Nurse Practitioner Certification

Transcription

1 ACNPC Endorsement Handbook (Adult) Acute Care Nurse Practitioner Certification

2 MISSION VISION VALUES ETHICS AACN Certification Corporation contributes to consumer health and safety through comprehensive credentialing of nurses to ensure their practice is consistent with established standards of excellence in caring for acutely and critically ill patients and their families. As the undisputed leader in credentialing nurses, AACN Certification Corporation has demonstrated that certification contributes to achieving optimal outcomes that are consistent with the goals and values of acutely and critically ill patients and their families. As the Corporation works to advance its mission and vision and fulfill its purpose and inherent obligation to ensure the health and well-being of patients experiencing acute and critical illness, the Corporation is guided by a set of deeply rooted values. Providing leadership to bring all stakeholders together to create and foster cultures of excellence and innovation. Acting with integrity and upholding ethical values and principles in all relationships and in the provision of sound, fair and defensible credentialing programs. Committing to excellence in credentialing programs by striving to exceed industry standards and expectations. Promoting leading edge, research-based credentialing programs that reach diverse certificants. Demonstrating stewardship through fair and responsible management of resources and cost-effective business processes. AACN and AACN Certification Corporation consider the American Nurses Association (ANA) Code of Ethics for Nurses foundational for nursing practice, providing a framework for making ethical decisions and fulfilling responsibilities to the public, colleagues and the profession. AACN Certification Corporation s mission of public protection supports a standard of excellence that certified nurses have a responsibility to read, understand and act in a manner congruent with the ANA Code of Ethics for Nurses. The following AACN Certification Corporation programs have been accredited by the National Commission for Certifying Agencies (NCCA), the accreditation arm of the Institute for Credentialing Excellence (ICE): CCRN (Adult) PCCN ACNPC-AG CCRN (Pediatric) CMC ACCNS-AG CCRN (Neonatal) CSC ACCNS-P CCRN-E TM (Adult) ACCNS-N Our advanced practice certification programs, ACCNS-AG, ACCNS-P, ACCNS-N and ACNPC-AG, meet the National Council of State Boards of Nursing (NCSBN) criteria for APRN certification programs.

3 Certification Organization for the American Association of Critical-Care Nurses ACNPC BY ENDORSEMENT HANDBOOK Certified Acute Care Nurse Practitioner - Adult As healthcare becomes increasingly complex and challenging, certification has emerged as a mark of excellence showing patients, employers and the public that a nurse is qualified and competent, and has met the rigorous requirements to achieve specialty and/or subspecialty certification. AACN Certification Corporation programs were created to protect healthcare consumers by validating the knowledge of nurses who care for the acutely and critically ill. We are pleased to provide you with this handbook with information about our programs and how to apply for ACNPC by Endorsement. Today, more than 93,000 practicing nurses hold one or more of these certifications from AACN Certification Corporation: Specialty Certifications CCRN is for nurses providing direct bedside care to acutely/critically ill adult, pediatric or neonatal patients. CCRN-E is for nurses working in a tele-icu monitoring acutely/critically ill adult patients from a remote location. CCRN-K is for nurses whose non-bedside practice influences patients, nurses and/or organizations to have a positive impact on the care delivered to acutely/critically ill adult, pediatric or neonatal patients. PCCN is for progressive care nurses providing direct bedside care to acutely ill adult patients. CNML is for nurse managers and leaders; offered in partnership with AONE (American Organization of Nurse Executives) Credentialing Center. Subspecialty Certifications CMC is for certified nurses providing direct bedside care to acutely/critically ill adult cardiac patients. CSC is for certified nurses providing direct bedside care to acutely/critically ill adult patients during the first 48 hours after cardiac surgery. Advanced Practice Consensus Model-Based Certifications ACNPC-AG is for the adult-gerontology acute care nurse practitioner educated at the graduate level. The ACCNS credentials are for clinical nurse specialists educated at the graduate level to provide care across the continuum from wellness through acute care: ACCNS-AG is for the adult-gerontology clinical nurse specialist. ACCNS-P is for the pediatric clinical nurse specialist. ACCNS-N is for the neonatal clinical nurse specialist. Advanced Practice Certifications With implementation of the Consensus Model in 2015, ACNPC and CCNS are available as renewal options only: ACNPC is for acute care nurse practitioners educated to provide care to adult patients. CCNS is for acute/critical care clinical care specialists educated to provide care to adult, pediatric or neonatal patients. We continually seek to provide quality certification programs that meet the changing needs of nurses and patients. Please visit > Documents and Handbooks, or call (800) for more information about the above certifications. Thank you for your commitment to patients and their families and to becoming certified. DECEMbEr 2015

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5 Contents Certification Program...4 ACNPC by Endorsement Application Process...5 ACNPC by Endorsement Eligibility requirements...6 Maintaining ACNPC Certification...6 ACNPC renewal Points Program Application Fees...9 Name and Address Changes...9 ACNPC by Endorsement Applications Option 1 - No Clinical Hours or CE Points (No Fee) Option 2 - Clinical Hours and CE Points AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA (800) Fax: (949) certcorp@aacn.org 3

6 Definition Certification is a process by which a nongovernmental agency validates, based upon predetermined standards, an individual nurse s qualifications and knowledge for practice in a defined functional or clinical area of nursing. ACNPC certification validates knowledge at entry-level as an acute care practitioner in the care of adult patients with complex acute and/or chronic health conditions to hospitals, peers, patients and, most importantly, to yourself. ACNPC certification promotes continuing excellence in acute care nursing. The purpose of certification renewal is to enhance continued competence. The ACNPC renewal process helps certificants maintain an up-to-date knowledge base. Code of Ethics AACN and AACN Certification Corporation consider the American Nurses Association (ANA) Code of Ethics for Nurses foundational for nursing practice, providing a framework for making ethical decisions and fulfilling responsibilities to the public, colleagues and the profession. AACN Certification Corporation s mission of public protection supports a standard of excellence that certified nurses have a responsibility to read, understand and act in a manner congruent with the ANA Code of Ethics for Nurses. To access the ANA Code of Ethics, visit > About AACN Certification Corp > Mission & Values. ACNPC Registered Service Mark ACNPC is a registered service mark and denotes certification as an adult acute care nurse practitioner as granted by AACN Certification Corporation. Those who have not achieved ACNPC certification or whose ACNPC certification has lapsed are not authorized to use the ACNPC credential. Administration and Sponsorship The certification programs are administered by AACN Certification Corporation. The certification exams are conducted in cooperation with Applied Measurement Professionals, Inc. (AMP). Membership Requirements There are no association membership requirements to participate in the ACNPC certification program. Nondiscrimination Policy It is the policy of AACN Certification Corporation, its board of Directors, committee members and staff to comply with all applicable laws that prohibit discrimination in employment or service provision because of a person s race, color, religion, gender, age, disability, national origin, or because of any other protected characteristic. Recognition of Certification CertifiCation Program Candidates who meet all eligibility requirements and pass the ACNPC certification exam or are approved for ACNPC Certification by Endorsement may use ACNPC after their licensing title. ACNPC is used in recognition of professional competence as an adult acute care nurse practitioner for a 5-year period of certification. ACNPC is a registered service mark. It is not punctuated with periods. The proper use of ACNPC is as follows: Chris Smith, rn, MSN, ACNPC. A listing of ACNPC-certified nurses is maintained by AACN Certification Corporation and may be reported in its publications and/or listed on its website. Certification status is available to the public via the online Certification Verification system, available at 4

7 acnpc By endorsement application ProCess 1. Submit the following in one envelope ACNPC by Endorsement application ACNPC application fee (if applicable) Copy of RN or APRN license Copy of ACNP wallet card, certificate or verification letter from certifying organization showing current certification as an adult acute care nurse practitioner 2. When joining AACN or renewing membership at the time of applying for ACNPC by Endorsement, write one check for the total amount payable to AACN Certification Corporation. Mail to: AACN Certification Corporation 101 Columbia Aliso Viejo, CA Or Fax to: (949) AACN offers 2-year and 3-year membership discounts. refer to application for pricing. AACN membership includes nonrefundable $12 and $15 oneyear subscriptions to Critical Care Nurse and the American Journal of Critical Care, respectively. AACN dues are not deductible as charitable contributions for tax purposes, but may be deducted as a business expense in keeping with Internal revenue Service regulations. 3. Waiting period for application processing Allow 1 to 4 weeks from date received at AACN for your application to be processed. AACN will notify you in writing if your application is incomplete or requires clarification, or if you are ineligible for endorsement. 4. Receive congratulations packet Certification by endorsement candidates will receive their wall certificate within 3 to 4 weeks of being approved. 5. Name and Address Changes You are responsible for notifying AACN Certification Corporation should your name and/or address change at any time before or after you become certified with AACN. Failure to do so may result in not receiving information necessary for certification renewal. Please notify us of any address or changes; you may update your profile: online at info@aacn.org, or call AACN Customer Care at (800) Name changes must be made by calling AACN Customer Care at (800)

8 acnpc By endorsement eligibility requirements If you are currently certified as an adult ACNP through the American Nurses Credentialing Center (ANCC) and meet the ACNPC by Endorsement requirements, you may choose to obtain ACNP certification through AACN Certification Corporation. Endorsement Eligibility Candidates must hold a current, unencumbered U.S. rn or APrN license. An unencumbered license has not been subjected to formal discipline by any state board of nursing and has no provisions or conditions that limit the nurse s practice in any way. This applies to all rn or APrN licenses you currently hold. Certificants must notify AACN Certification Corporation within 30 days if any restriction is placed on their APrN or rn license(s). Candidates must be currently certified as an adult ACNP through the American Nurses Credentialing Center (ANCC). Note: AACN Certification Corporation was in a joint partnership with ANCC from 1995 through 2001 to develop and administer the adult ACNP exam. All NP educational programs are required to meet national educational standards and exams are required to meet national accreditation standards, which results in equivalency among APrN certifiers. Endorsement Options ACNP certificants wishing to obtain ACNPC by Endorsement may choose one of the following two options anytime during their current active ACNP certification period. Option 1 - No Clinical Hours or CE Points Within the certificant s current 5-year certification period, apply for ACNPC certification by endorsement. There is no fee for this option. The ACNPC certification expiration date will be the same as the certificant s current ANCC ACNP certification expiration date. If your ANCC expiration date is not on the last day of the month, your ACNPC expiration date will fall on the last day of the prior month. Complete and submit application on pages Option 2 - Clinical Hours and CE Points Within the 5-year period prior to application, candidates must work a minimum of 1,000 clinical hours and complete 150 CE Points meeting the clinical hour and CE Points requirements as outlined on pages 7 and 8. The ACNPC certification expiration date will be 5 years from the first day of the month in which the ACNPC endorsement application is signed. Complete and submit the application on pages and include fee. Clinical Hour Requirement (Option 2 only) The clinical hour requirement for ACNPC certification is defined as active involvement in the direct care of acutely ill adult patients. Care is defined by the performance of activities that exemplify the 8 characteristics that contribute to optimal outcomes. This care may be directed toward a patient/population, nursing personnel and/or other disciplines/organizations/systems. An individual applying for ACNPC by Endorsement must have been actively involved in the care of acutely ill adult patients in the role of the acute care nurse practitioner for a minimum of 1,000 hours over the 5-year certification period. Hours spent by faculty members supervising the acute care clinical practice of APRN students may be counted toward the clinical hour requirement for ACNPC certification. Eligible practice hours for ACNPC by Endorsement are those completed within the U.S. ACNPs practicing outside the U.S. should contact AACN at APrNcert@aacn.org regarding eligible practice hours. See the following pages for CE Points Program details. maintaining acnpc CertifiCation Once ACNPC is obtained, you must complete one of three renewal options prior to your certification expiration date to maintain the credential. The ACNPC by Endorsement program does not allow a certificant repeated ACNPC endorsements should their certification expire. For complete details, please refer to the ACNPC Renewal Handbook available at > Documents and Handbooks. 6

9 acnpc Ce renewal Points Program Category I - Acute Care Education Programs At least 75 of the 150 required CE Points must be in this category. All 150 CE Points may be in this category. A. Formally Approved Programs This area encompasses acute care programs granting approved continuing education credit(s) such as CE, CNE, CME or ACPE and academic credit courses. Acceptable programs must possess one of the following characteristics: Have direct application to meeting the needs of the adult patient population. Address clinical knowledge, skills and abilities utilized by adult ACNPs. Twenty-five (25) CE Points in Category I must be pharmacology-focused: Pharmacology content must be at the advanced practice level and related to the APrN s licensed advanced role and population focus. To determine the number of CE Points for programs providing CEs, CNEs or CMEs that don t specify pharmacology hours and programs that don t provide formal contact hours, but include pharmacology content, use the following calculation: 60 minutes = 1 CE Point. If audited, submit the educational presentation or conference agenda as evidence to validate the CE point calculation and include a narrative note describing pharmacology content within agenda. These programs need NOT be approved by the American Association of Critical-Care Nurses and may be offered by hospitals, professional associations or independent education groups. Home study or self-study programs from professional journals and other sources that grant contact hours apply to Category I. Continuing Medical Education (CME) may account for no more than 50% of the total points in Category I. If an academic credit course specific to care of the acutely-ill patient population is completed, CE can be awarded in Category I. For academic credit courses, one (1) credit is worth 15 CEs. For example, a 3-credit course would be worth 45 CEs. Eligible courses include, but are not limited to: Physical assessment Anatomy/physiology/pathophysiology Diagnostic tests used in acute and critical care settings (e.g., AbG interpretation, cardiac angiography, x-ray and lab interpretation) Concerns regarding the acute or critical care environment (e.g., infection control) Psychological or behavioral responses of the patient and family (e.g., sensory deprivation, patient teaching, nursing diagnosis) Issues pertaining to the patient care environment (e.g., ethical and legal issues) Therapies, interventions or knowledge vital to patient management (e.g., fluid dynamics, bls, ACLS, PALS, NrP, ECG interpretation, nutritional support, pain management, IV therapy, pharmacology) Applied clinical research B. Continuing Education Programs Not Formally Approved Includes AACN chapter programs, hospital in-services, workshops, study modules, etc. May account for no more than 25 CE Points in Category I. Category II - Optional Activities Optional activities may only account for 75 of the 150 required CE Points. Optional activities are not required. A. Professional Publications Encompasses professional nursing publications. responsibility in the publication may be authorship, co-authorship or editorial. The item to be published may be a book, chapter in a book, paper, article, abstract, book reviews, etc. Professionally authored multimedia aids are acceptable (points for joint authorships are determined by dividing the number of points to be awarded by the number of authors). continued 7

10 acnpc Ce renewal Points Program (CONTINUED) Number of CEs Points Awarded Editorial in a journal 5 Write a column for a journal 10 Article in a local newsletter or AACN chapter newsletter 3 Original research article (peer reviewed) 30 Textbook or chapter editor Textbook author less than 300 pages 30 Textbook author more than 300 pages 60 Professionally authored multimedia aids 15 research abstract 5 Journal article (peer reviewed) 20 Journal reviewer (articles or book chapters) 5 book reviews 5 Unpublished master s thesis or equivalent final project 30 Doctoral dissertation or equivalent final project 45 Service on editorial boards B. Professional Presentations 2 points / 10 pages (max 30) 5 points per board per year Encompasses the certificant s participation as an instructor delivering content related to the adult patient population to nurses, other healthcare professionals or the public. See the ACNPC Test Plan for acceptable topics. The presentation must be delivered within a structured framework of teaching/learning. A presentation includes a seminar, in-service, clinical conference, patient/family education program, consumer education program, AACN chapter educational activities and/or presenting an original paper or poster. The participation may be as a primary instructor, member of a team, guest lecturer, panel participant, etc. No credit is given for repeat presentations of the same content. 6 points per hour of lecture given If the program is co-taught, the number of points to be awarded is determined by dividing points by the number of instructors. NOTE: Activities regularly completed as the focus of employment may not be counted. For example, if you regularly teach in your hospital s orientation program, you may not count those presentations; however, you may count presentations given on a newly researched topic for NTI or for your chapter, etc. C. Preceptorship or Volunteer Activities Participating in activities/teams/committees that solve or prevent complex problems or improve care, across multiple departments, settings, facilities or regions such as spearheading a major patient care improvement; and leading an interdisciplinary team to solve a problem. 10 points per year NOTE: Activities regularly completed as the focus of employment may not be counted. For example, as one of your hospital s acute care NPs, if you are automatically assigned to the rapid response team, you may not count this participation. Participation in leadership responsibilities or committee involvement on a chapter/regional level. 10 points per committee per year Leadership responsibilities or committee involvement in professional, governmental or health related organizations. 10 points per committee per year Preceptorship/mentorship A minimum of 80 hours per year of preceptorship activity must be obtained in order for points to be granted. 10 points per year NOTE: Activities regularly completed as the focus of employment may not be counted. If you are precepting an APrN student from a graduate program and are not faculty in that program, you may count those hours. You may not count hours spent precepting or teaching undergraduate students. 8

11 acnpc By endorsement application fees Option 1 - No Clinical Hours or CE Renewal Points Expiration date will be same as ANCC certification. AACN Members Nonmembers No Fee No Fee Option 2 - Clinical Hours and CE Renewal Points AACN Members $200 Nonmembers $305 Payable in U.S. funds. Fees are subject to change without notice. A $15 fee will be charged for a returned check. If you are determined to be ineligible for ACNPC certification your application fee will be refunded. name and address Changes renewal notices are sent starting 4 months prior to your certification expiration date. You are responsible for notifying AACN Certification Corporation should your name and/or address change at any time after you become certified. Failure to do so may result in not receiving information necessary for certification renewal. Please notify us of any address or address changes; you may update your profile as follows: online at info@aacn.org, or call AACN Customer Care at (800) The following changes must be made by calling AACN Customer Care at (800) name changes address changes for exam candidates during 90-day testing window Candidates are responsible for renewing their certification even if they do not receive a renewal notice. 9

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13 1 of 2 FOR OPTION 1 application - acnpc By endorsement (NO FEE / SAME ExPIrATION AS ANCC CErTIFICATION) For Adult ACNPs certified through ANCC who wish to endorse over to AACN with the same renewal period. 1. REGISTRATION INFORMATION PLEASE PRINT CLEARLY. PROCESSING WILL BE DELAYED IF INCOMPLETE OR NOT LEGIBLE. AACN CuSTOMER: LEGAL NAME: HOME ADDRESS: EMPLOYER NAME: RN/APRN LICENSE: Number Exp. Date Number State Exp. Date Last First MI Maiden City State ZIP HOME PHONE: BuSINESS PHONE: EMPLOYER ADDRESS: City State ZIP 2. DEMOGRAPHIC INFORMATION Check one box in each category. Information used for statistical purposes and may be used in eligibility determination. Primary Area Employed Acute Hemodialysis Unit (21) burn Unit (13) Cardiac rehabilitation (26) Cardiac Surgery/Or (36) Cardiovascular/Surgical ICU (09) Catheterization Lab (22) Combined Adult/Ped. ICU (23) Combined ICU/CCU (01) Coronary Care Unit (03) Corporate Industry (24) Crit. Care Transport/Flight (17) Direct Observation Unit (39) Emergency Dept. (12) General Med./Surg. Floor (18) Home Care (25) Intensive Care Unit (02) Interventional Cardiology (31) Long-Term Acute Care (27) Medical Cardiology (34) Medical ICU (04) Medical Surgical ICU (35) Neonatal ICU (06) Neuro./Neurosurgical ICU (10) Oncology Unit (19) Operating room (15) Outpatient Clinic (29) Pediatric ICU (05) Private Practice (32) Progressive Care Unit (16) recovery room/pacu (14) respiratory ICU (08) Stepdown Unit (30) Subacute Care (28) Surgical ICU (07) Tele-ICU (37) Telemetry (20) Trauma Unit (11) Other specify below (99) Primary Position Held Academic Faculty (07) Acute Care Nurse Practitioner (09) bedside/staff Nurse (01) Case Manager (39) Charge Nurse (45) Clinic Nurse (40) Clinical Coordinator (44) Clinical Director (04) Clinical Nurse Specialist (08) Corporate/Industry (11) Hospital Administrator (38) Internist (37) Legal Nurse Consultant (47) Manager (03) Nurse Anesthetist (02) Nurse Educator (46) Nurse Midwife (13) Nurse Practitioner (05) Outcomes Manager (42) Physician (16) Physician Assistant (17) researcher (18) respiratory Therapist (19) Technician (21) Unit Coordinator (22) Other - specify below (99) Highest Nursing Degree Associate s Degree bachelor s Degree Diploma Doctorate Master s Degree Home Health (13) Long-Term Acute Care Hosp. (16) Military/Government Hospital (04) Non-Academic Teaching Hosp. (14) registry (10) Self-Employed (09) State Hospital (06) Travel Nurse (15) University Med. Ctr. (03) Other specify below (99) Ethnicity African American (02) Asian (05) Number of Beds in Institution: Hispanic (03) Native American (04) Years of Experience in Nursing: Pacific Islander (06) White/Non-Hispanic (01) Other specify below (99) Primary Type of Facility in Which Employed College/University (08) Community Hospital (Nonprofit) (01) Years of Experience in Acute/Critical Care Nursing: Date of Birth: (mm/dd/yy) Community Hospital (Profit) (02) Corporate/Industry (11) County Hospital (07) Federal Hospital (05) HMO/Managed Care (12) Gender: Female Male Please complete page 2 of application. APCAPW This application form may be photocopied and is available online at DECEMbEr

14 2 of 2 For Adult ACNPs certified through ANCC who wish to endorse over to AACN with the same renewal period. PLEASE PRINT CLEARLY. FOR OPTION 1 honor statement - acnpc By endorsement NAME: AACN CuSTOMER #: Last First MI 3. HONOR STATEMENT I hereby apply for ACNPC certification. I have read and understand the eligibility requirements as documented in the ACNPC by Endorsement Handbook. I hold current certification as an adult acute care nurse practitioner through the American Nurses Credentialing Center (ANCC), which is due to expire (date). I understand that my ACNPC certification, once approved, will be valid through the month prior to when my ANCC certification is due to expire, regardless of the date this application is signed. LICENSuRE: I possess a current, unencumbered U.S. rn or APrN license. My (state) nursing license (number) is due to expire (date). An unencumbered license is not currently being subjected to formal discipline by any state board of nursing and has no provisions or conditions that limit my practice in any way. This applies to all rn or APrN licenses I currently hold. I understand that I must notify AACN Certification Corporation within 30 days if any restriction is placed on my rn or APrN license(s) in the future. AuDIT: I understand that my certification application is subject to audit, and failure to respond to or pass an audit will result in revocation of certification. ETHICS: I understand the importance of ethical standards and agree to act in a manner congruent with the ANA Code of Ethics for Nurses. upon approval of my application please send verification of my ACNPC certification to the State Board of Nursing. To the best of my knowledge, the information contained in this application is accurate and submitted in good faith. My signature below indicates I have read this honor statement and meet the eligibility requirements as outlined. Applicant s Signature: Date: 4. AACN MEMBERSHIP (OPTIONAL) I would like to join/renew my AACN membership at this time: (check one box only) 1-year AACN membership.$78 2-year AACN membership.$148 3-year AACN membership. $200 AACN membership includes nonrefundable $12 and $15 one-year subscriptions to Critical Care Nurse and the American Journal of Critical Care, respectively. AACN dues are not deductible as charitable contributions for tax purposes, but may be deducted as a business expense in keeping with Internal revenue Service regulations. Check or money order attached payable to AACN Certification Corporation. U.S. funds only. bill my credit card Visa MasterCard American Express Discover Card Credit Card # Exp. Date (mm/yy) Name on Card Signature Amount billed $ Address of Payor (if different than applicant) Please do not include my name on lists sold to other organizations. 5. SuBMIT APPLICATION/DOCuMENTATION Attach the following to this application: Copy or online printed version of rn or APrN license Copy of current ACNP certification (wallet card, certificate or verification letter from certifying organization) Submit (with payment, if applicable) to: AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA Or Fax to: (949) NOTE: Allow 1 to 4 weeks from the date received by AACN Certification Corporation for application processing. 12 Questions? Please visit certification@aacn.org or call us at (800) This form may be photocopied and is also available online at DECEMbEr 2015

15 1 of 3 FOR OPTION 2 application - acnpc By endorsement For Adult ACNPs certified through ANCC who want their ACNPC certification to begin the month this application is signed. 1. REGISTRATION INFORMATION PLEASE PRINT CLEARLY. PROCESSING WILL BE DELAYED IF INCOMPLETE OR NOT LEGIBLE. AACN CuSTOMER: LEGAL NAME: HOME ADDRESS: RN/APRN LICENSE: Number Exp. Date Number State Exp. Date Last First MI Maiden City State ZIP HOME PHONE: EMPLOYER NAME: BuSINESS PHONE: EMPLOYER ADDRESS: 2. AACN MEMBERSHIP City State ZIP I would also like to join/renew my AACN membership at this time and select member pricing for my exam fees: (check one box only) 1-year AACN membership.$78 2-year AACN membership.$148 3-year AACN membership. $200 AACN membership includes nonrefundable $12 and $15 one-year subscriptions to Critical Care Nurse and the American Journal of Critical Care, respectively. AACN dues are not deductible as charitable contributions for tax purposes, but may be deducted as a business expense in keeping with Internal revenue Service regulations. Please do not include my name on lists sold to other organizations. 3. ACNPC CERTIFICATION FEES: $200 ACNPC Certification by Endorsement AACN Member $305 ACNPC Certification by Endorsement Nonmember 4. PAYMENT INFORMATION application must be accompanied by payment Check or money order attached payable to AACN Certification Corporation. U.S. funds only. bill my credit card Visa MasterCard American Express Discover Card Membership Fee: $ + Certification Fee: $ = Total Payment: $ Credit Card # Exp. Date (mm/yy) Name on Card Signature Amount billed $ Address of Payor (if different than applicant) Please complete pages 2 and 3 of application. APCAPW This form may be photocopied and is available online at DECEMbEr

16 2 of 3 FOR OPTION 2 application - acnpc By endorsement For Adult ACNPs certified through ANCC who want their ACNPC certification to begin when this application is signed. PRINTED LEGAL NAME: AACN#: 5. DEMOGRAPHIC INFORMATION Check one box in each category. Information used for statistical purposes and may be used in eligibility determination. Primary Area Employed Acute Hemodialysis Unit (21) burn Unit (13) Cardiac rehabilitation (26) Cardiac Surgery/Or (36) Cardiovascular/Surgical ICU (09) Catheterization Lab (22) Combined Adult/Ped. ICU (23) Combined ICU/CCU (01) Coronary Care Unit (03) Corporate Industry (24) Crit. Care Transport/Flight (17) Direct Observation Unit (39) Emergency Dept. (12) General Med./Surg. Floor (18) Home Care (25) Intensive Care Unit (02) Interventional Cardiology (31) Long-Term Acute Care (27) Medical Cardiology (34) Medical ICU (04) Medical Surgical ICU (35) Neonatal ICU (06) Neuro./Neurosurgical ICU (10) Oncology Unit (19) Operating room (15) Outpatient Clinic (29) Pediatric ICU (05) Private Practice (32) Progressive Care Unit (16) recovery room/pacu (14) respiratory ICU (08) Stepdown Unit (30) Subacute Care (28) Surgical ICU (07) Tele-ICU (37) Telemetry (20) Trauma Unit (11) Other specify below (99) Primary Position Held Academic Faculty (07) Acute Care Nurse Practitioner (09) bedside/staff Nurse (01) Case Manager (39) Charge Nurse (45) Clinic Nurse (40) Clinical Coordinator (44) Clinical Director (04) Clinical Nurse Specialist (08) Corporate/Industry (11) Hospital Administrator (38) Internist (37) Legal Nurse Consultant (47) Manager (03) Nurse Anesthetist (02) Nurse Educator (46) Nurse Midwife (13) Nurse Practitioner (05) Outcomes Manager (42) Physician (16) Physician Assistant (17) researcher (18) respiratory Therapist (19) 6. COMPLETE AND SIGN HONOR STATEMENT ON NExT PAGE Technician (21) Unit Coordinator (22) Other - specify below (99) Highest Nursing Degree Associate s Degree bachelor s Degree Diploma Doctorate Master s Degree Home Health (13) Long-Term Acute Care Hosp. (16) Military/Government Hospital (04) Non-Academic Teaching Hosp. (14) registry (10) Self-Employed (09) State Hospital (06) Travel Nurse (15) University Med. Ctr. (03) Other specify below (99) Ethnicity African American (02) Asian (05) Number of Beds in Institution: Hispanic (03) Native American (04) Years of Experience in Nursing: Pacific Islander (06) White/Non-Hispanic (01) Other specify below (99) Primary Type of Facility in Which Employed College/University (08) Community Hospital (Nonprofit) (01) Years of Experience in Acute/Critical Care Nursing: Date of Birth: (mm/dd/yy) Community Hospital (Profit) (02) Corporate/Industry (11) County Hospital (07) Federal Hospital (05) HMO/Managed Care (12) Gender: Female Male 7. SuBMIT APPLICATION AND DOCuMENTATION Attach the following to this application: Copy or online printed version of rn or APrN license Copy of current ACNP certification (wallet card, certificate or verification letter from certifying organization) Submit with payment to: AACN Certification Corporation 101 Columbia Aliso Viejo, CA or fax to: (949) NOTE: Allow 1 to 4 weeks from the date received by AACN Certification Corporation for application processing. Questions? Please visit certification@aacn.org or call us at (800) Did you include fee payment and copies of your rn or APrN license and ACNP certification? DECEMbEr 2015

17 3 of 3 FOR OPTION 2 honor statement - acnpc By endorsement For Adult ACNPs certified through ANCC who want their ACNPC certification to begin when this application is signed. PLEASE PrINT CLEArLY. NAME: AACN CuSTOMER #: Last First MI I hereby apply for ACNPC certification. Submission of this application indicates I understand and have met the eligibility requirements as documented in the ACNPC by Endorsement Handbook. I acknowledge that certification depends upon successful completion of the specified requirements. I hold current certification as an adult acute care nurse practitioner through the American Nurses Credentialing Center (ANCC). LICENSuRE: I possess a current, unencumbered U.S. rn or APrN license. My (state) nursing license (number) is due to expire (date). An unencumbered license is not currently being subjected to formal discipline by any state board of nursing and has no provisions or conditions that limit my practice in any way. This applies to all rn or APrN licenses I currently hold. I understand that I must notify AACN Certification Corporation within 30 days if any restriction is placed on my APrN or rn license(s) in the future. PRACTICE: I understand that a significant component of APrN practice focuses on direct care of individuals. During the last 5 years, I have completed 1,000 hours as an APrN in the care of acutely ill adult patients in the role of the acute care nurse practitioner. PRACTICE VERIFICATION: Following is the contact information of my supervisor or a professional colleague (rn or physician) who can verify that I have met the practice hour requirements: VERIFIER S NAME: Last First FACILITY NAME: VERIFIER S PHONE NuMBER: You may not list yourself or a relative as your verifier. VERIFIER S ADDRESS: CONTINuED COMPETENCE: In the last 5 years I have completed 150 CE renewal Points, with at least 75 in the area of Acute Care Education Programs and 25 in pharmacology, as defined in the ACNPC CE renewal Points Program. AuDIT: I understand that my certification application is subject to audit, and failure to respond to or pass an audit will result in revocation of certification. ETHICS: I understand the importance of ethical standards and agree to act in a manner congruent with the ANA Code of Ethics for Nurses. upon approval of my application please send verification of my ACNPC certification to the State Board of Nursing. To the best of my knowledge, the information contained in this application is accurate and submitted in good faith. My signature below indicates I have read this honor statement and meet the eligibility requirements as outlined. Applicant s Signature: Date: Please allow 1 to 4 weeks from the date received by AACN Certification Corporation for processing of your application. DECEMbEr 2015 This form may be photocopied and is also available online at 15

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