Course Waiver Form for FNP/DNP or DNP in Practice Leadership Applicants
Please complete this form for each course you would like considered for a waiver. Courses must have been completed within 5 years
prior to the application deadline. Along with this waiver request from, also complete and send (upload, fax, mail or email) course
syllabus for each course (not a course description). If you are accepted to the FNP/DNP program, you will be notified in the letter of
admission whether the course has been accepted for a waiver.
Note: The Program faculty’s determination of whether to waive a course requirement for an applicant requires a careful and
comprehensive assessment of the course. We recognize that some applicants may wish to have a preliminary review prior to
submitting their application, but we regret that we cannot do so.
If you have any trouble completing this form, please contact us at 617-521-2605 or firstname.lastname@example.org for assistance.
Last (Family or Surname) First (Given) Former
Title and Name of Course:
I want to use this course to waive the following Simmons DNP course: ___________________________________________________________
For a list of DNP core courses, please visit http://www.simmons.edu/snhs/programs/nursing/dnp/curriculum.php
Title/Author of Textbook Used: ________________________________________________________________________________________________
Number of credit hours: ______
Total number of class hours per week: ______ Total number class hours per term: ______
Month/Year course completed: _____ / _____ (eg. 05/2002)
Length of course in weeks (indicate system used):
Semester system: Indicate number of weeks: ____
Quarter System: Indicate number of weeks: ____
Trimester System: Indicate number of weeks: ____
Name of institution where course was/is taught: _________________________________________________________________________________
Institution is regionally accredited by which professional association (check the institutional catalog or website)?
Online course: ___Yes ___No
Lab included (for science courses)? ___Yes ___No
Please attach a course syllabus that provides the following info:
• Name of instructor
• Year course taught
• Textbook used
• Method of course assessment
A course description (a general statement of the course content) from a college/university catalog is NOT acceptable.
THIS FORM MUST BE FULLY COMPLETED AND SUBMITTED ALONG WITH THE COURSE SYLLABUS IN ORDER FOR AN EVALUATION TO BE
COMPLETED. MISSING ITEMS WILL DELAY THE PROCESS.