Doug Ducey Joey Ridenour
Governor
Executive Director
Arizona State Board of Nursing
Nursing Student Request for Waiver
Nursing Assistant Certification Education
APPLICANT INFORMATION
I hereby certify that the information provided is true and correct. I also certify that I have read Nurse Practice
Act Statutes and Rules, ARS § 32-1645 and R-4-19-806 through R-4-19-815, and understand the qualifications
and responsibilities of a certified nursing assistant.
Signature of Applicant for Waiver
The following waiver applies to applicants that have not completed a Board approved nursing assistant training
program:
NURSING STUDENT WAIVER AND INSTRUCTOR VERIFICATION
Nursing students who, within the past 2 years, have successfully completed a nursing course as part of an
approved RN/LPN program including: didactic content relating to Long Term Care clients; 40 hours of patient
care in a long-term care (LTC )or comparable facility; and documentation of meeting requirements from the
course instructor or nursing program director/designee.
Name and Address of School
Name of course (s) providing didactic instruction in
LTC Clients
course (s)
Name of LTC facility where student spent a minimum
of 40 hours in resident care
From:
To:
Total clock hours of clinical
in LTC facility
Signature of Instructor or Program Director attesting
to the veracity of the above information
