FOR OFFICE USE ONLY
Practice Hours Requirement Evaluation
Practice Hour Requirement
CNAs - 8 hours past 2 years
LNAs - 160 hours past 2 years
provided the following nursing assistant duties at
LNA or CNA Caregiver's Name (print)
□
8 hours for CNA
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160 hours for LNA
Employer's Name or Facility Name (print)
Check all duties CNA/Caregiver provided
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Vital Signs
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Transfers - bed to wheelchair
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Ambulation
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Intake & Output
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Denture/Oral care
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Weight
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Range of motion
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Specimen collection
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Feeding and hydration
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Observe & report pain
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Bathing
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Apply clean bandages
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Skin care
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Change soiled briefs
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Turning & repositioning in bed
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Hair care
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Nail care
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Dressing the patient
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Toileting
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Perineal care
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Maintaining a patient's environment
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Recognizing and reporting abnormal changes
Dates of care: from
/
/to
//
Employer Signature and Title
Date
Address:
Phone: Email:
Employer must complete all the information below. Return
completed form with your renewal application to AZBN.
LNAs or CNAs who are Caregivers whose practice
hours are worked in a facility or setting that does not
require you to be a LNA/CNA. Family care does not
qualify as meeting practice requirements.
ARIZONA STATE BOARD OF NURSING
1740 W Adams Street, Suite 2000
Phoenix, AZ 85007
Home Page: www.azbn.gov
