Fillable Arizona State Board of Nursing (Arizona State Board of Nursing)

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Arizona State Board of Nursing (Arizona State Board of Nursing)

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Country of origin: US
File type: PDF

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BROWSE ARIZONA STATE BOARD OF NURSING (AZ) FORMS

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Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
NURSING ASSISTANT TRAINING PROGRAM
CONSOLIDATED SITE RENEWAL APPLICATION SUPPLEMENTAL SHEET
(Complete one sheet for each consolidated site utilized at any time in the past 2 years and submit with
main* renewal application and application checklist)
Main* Program Name
and Location:
Program Code #:
Consolidated Site Name: Program Code #:
Site Phone #:
Website Address:
Physical Address of Site:
Mailing Address of Site:
Coordinator Name:
Office phone:
Email Address:
Fax:
Site Instructor Name:
Office phone:
Email Address:
Fax:
Site Instructor Name:
Office phone:
Email Address:
Fax:
List all clinical sites that will be utilized by this site:
Graduates and Pass Rates since Last Approval (for this site only)
Session or
Semester
(e.g. Summer
2014)
Number of
Students
Enrolled
(e.g. 18)
Number of
Graduates
(e.g. 16)
Number of
Graduates
that tested
(e.g. 16)
Written Exam
Number of Students
(first time—pass rates)
(e.g. 14/89%)
Skills Exam
Number of Students
(first time—pass rates)
(e.g. 14/89%)
Total
(if more sessions completed—please continue chart on next page)
Please attach Evaluation Plan and Results for this site
*Main Location is where all files are kept
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Arizona State Board of Nursing (Arizona State Board of Nursing)

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Completed 12 August 2020

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