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ACNPC Endorsement Handbook

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					MISSION
      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.

VISION
      As the undisputed leader in credentialing nurses, the 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.

VALUES
      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.

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.

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):

                  · Adult CCRN® and CCRN-ETM
                  · Pediatric and Neonatal CCRN®
                  · Adult, Pediatric and Neonatal CCNS®
                  · Adult ACNPC®
                  · Adult CMC®
                  · Adult CSC®

Our advanced practice certification programs, CCNS and ACNPC, have also been recognized by the National
Council of State Boards of Nursing (NCSBN).
                   Certification Organization for the American Association of Critical-Care Nurses




           ACNPC BY ENDORSEMENT HANDBOOK
                 for Certified Adult Acute Care Nurse Practitioners

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 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 72,000 practicing nurses hold one or more of these certifications from aaCN
Certification Corporation:

• CCRN® specialty certification introduced in 1976 for nurses providing care to acutely and/or
  critically ill adult, pediatric and neonatal patients.
• CCRN-E™ specialty certification introduced in 2007 as a renewal option and in 2011 as an initial
  exam option for nurses working in a tele-ICu monitoring acutely and/or critically ill adult patients
  from a remote location (behind a camera).
• PCCN® specialty certification introduced in 2004 for progressive care nurses providing care to
  acutely ill adult patients.
• CCNS® entry-level advanced practice specialty certification launched in 1999 for clinical nurse
  specialists educated at the graduate level to provide advanced nursing care to acutely or critically
  ill adult, pediatric or neonatal patients.
• ACNPC® entry-level advanced practice specialty certification launched in 2007 for nurses educated
  at the graduate level to provide advanced nursing care across the continuum of health services to
  meet the specialized physiologic and psychological needs of adult patients with complex acute
  and/or chronic health conditions.
• CNML certification for nurse managers launched in 2008 in partnership with the american
  Organization of Nurse Executives (aONE).
• CMC® subspecialty certification launched in 2005 for certified nurses providing care to acutely
  and/or critically ill adult cardiac patients.
• CSC® subspecialty certification launched in 2005 for certified nurses providing care to acutely
  and/or critically ill adult patients during the first 48 hours after cardiac surgery.
We continually seek to provide quality certification programs that meet the changing needs of nurses
and patients. Please visit www.certcorp.org > Documents and Handbooks or call (800) 899-2226 for
more information about the above certifications.
thank you for your commitment to patients and their families and to becoming certified.


                                                                                                     august 2012

                                                                                                                   1
2
                                                                             Contents


Certification Program .......................................................................................................................................................4
aCNPC By Endorsement application Process .................................................................................................................5
aCNPC By Endorsement Eligibility Requirements ..........................................................................................................6
aCNPC Renewal Points Program ..................................................................................................................................7-8
Maintaining aCNPC Certification .....................................................................................................................................8
application Fees ...............................................................................................................................................................9
Name and address Changes ...........................................................................................................................................9

ACNPC by Endorsement Applications
Option 1 - No Clinical Hours or CE Points (and No Fee).........................................................................................11-12
Option 2 - Clinical Hours and CE Points ..................................................................................................................13-15




                                 AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656-4109
                                       (800) 899-2226 • Fax: (949) 362-2020 • certcorp@aacn.org




                                                                                                                                                                               3
                                        CertifiCation Program

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 advanced 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 you
maintain an up-to-date knowledge base. In addition to providing you with a sense of professional pride and
achievement, aCNPC certification recognizes attainment of the special knowledge and experience required for
recognition as an advanced practice nurse.

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
www.certcorp.org > about aaCN Certification Corp > Mission & Values.

ACNPC® Registered Service Mark
aCNPC is a registered service mark of aaCN Certification Corporation 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
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
www.certcorp.org.
4
                      aCnPC By endorsement aPPliCation ProCess


1. submit the following in one envelope                 Mail to:
    • ACNPC by Endorsement application                  aaCN Certification Corporation
                                                        101 Columbia
    • ACNPC application fee (if applicable)             aliso Viejo, Ca 92656-4109
    • Copy of APRN license or RN license in states
      where aPRN licenses are not issued                Or Fax to:
    • Copy of ACNP certificate or wallet card           (949) 362-2020
      showing current certification as an adult acute
      Care Nurse Practitioner

2. When joining AACN or renewing membership at          aaCN offers 2-year and 3-year membership discounts. Refer to
   the time of applying for aCNPC by Endorsement,       application for pricing.
   write one check for the total amount payable to
   aaCN Certification Corporation.                      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.
3. Waiting period for application processing            allow 2 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 the 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 email changes; you may
                                                        update your profile:
                                                          • online at www.aacn.org/myaccount,
                                                          • email info@aacn.org, or
                                                          • call aaCN Customer Care at (800) 899-2226
                                                        Name changes must be made by calling aaCN Customer Care at
                                                        (800) 899-2226.




                                                                                                                                5
                    aCnPC By endorsement eligiBility requirements

If you are currently certified as an adult aCNP through        Option 2 - Clinical Hours and CE Points
the american Nurses Credentialing Center (aNCC)                Within the five (5) year period prior to application,
and meet the aCNPC Certification by Endorsement                candidates must work a minimum of 1,000 clinical
requirements, you may choose to obtain aCNP                    hours and complete 150 CE Points meeting the clinical
certification through aaCN Certification Corporation.          hour and CE Points requirements as outlined on pages
                                                               7 and 8.
ACNPC by Endorsement Eligibility
Candidates must:                                               the aCNPC certification expiration date will be five (5)
                                                               years from the first day of the month in which the
    • Hold a current unencumbered RN or aPRN                   aCNPC endorsement application is signed. Complete
      licensure in the united states. an unencumbered          and submit application on pages 13-15 and include
      license has not been subjected to formal discipline      fee.
      by any state board of nursing and has no provi-
      sions or conditions that limit the nurse's practice
      in any way. Certificants must notify aaCN                Clinical Hour Requirement (Option 2 only)
      Certification Corporation within 30 days if any          the clinical hour requirement for aCNPC certification is
      restriction is placed on their RN or aPRN license.       defined as active involvement in the direct care of
    • Be currently certified as an adult aCNP through the      acutely ill adult patients. Care is defined by the per-
      american Nurses Credentialing Center (aNCC).             formance of activities that exemplify the eight charac-
                                                               teristics that contribute to optimal outcomes. this care
Note: aaCN Certification Corporation was in a joint            may be directed toward a patient/population, nursing
partnership with aNCC from 1995 through 2001 to                personnel and/or other disciplines/organizations/sys-
develop and administer the adult aCNP exam. all NP             tems.
educational programs are required to meet national
educational standards and examinations are required            an individual applying for aCNPC by Endorsement must
to meet national accreditation standards, which results        have been actively involved in the direct care of acutely
in equivalency among aPRN certifiers.                          ill adult patients in the role of the acute care nurse
                                                               practitioner for a minimum of 1,000 hours over the
ACNPC by Endorsement Options                                   5-year certification period.
aCNP certificants wishing to obtain aCNPC by
                                                               Hours spent by faculty members supervising the acute
Endorsement may choose one of the following two
                                                               care clinical practice of their aPRN students may be
options anytime during their current active aCNP
                                                               counted toward the clinical hour requirement for
certification period.
                                                               aCNPC certification.
Option 1 - No Clinical Hours or CE Points                      Clinical practice hours for aCNPC by Endorsement
Within the certificant’s current five (5) year certification   must take place in a u.s.-based facility or in a facility
period, apply for aCNPC certification by endorsement.          determined to be comparable by verifiable evidence to
there is no fee for this option.                               the u.s. standard of acute care nursing practice, as
                                                               evidenced by aNCC Magnet status or Joint Commission
the aCNPC certification expiration date will be the            International accreditation.
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 11-12.




6
                                  Ce renewal Points Program

Category I - Acute Care Education Programs Category II - Optional Activities
At least 75 of the 150 required CE points must be in      Optional Activities may only account for 75 of the 150
this category.                                            required CE points. Optional activities are not required.

A. Programs Granting Contact Hours (including CEs,        A. Professional Publications
CMEs, CNE or academic courses)                            Encompasses professional nursing publications.
                                                          Responsibility in the publication may be authorship,
at least 50 of the required 75 CE points must be in       co-authorship or editorial. the item to be published
this category (I.a.). Continuing Medical Education        may be a book, chapter in a book, paper, article,
(CMEs) may account for no more than 25 CE points.         abstract, book reviews, etc. Professionally authored
                                                          multimedia aids are acceptable (points for joint
Effective January 1, 2014, 25 pharmacology CEs            authorships are determined by dividing the number of
are required.                                             points to be awarded by the number of authors).

this area encompasses acute care programs granting        Number of CEs Points Awarded
contact hours or CEs. acceptable programs must
possess one of the following characteristics:              Editorial in a journal                      5

 • Have direct application to meeting the needs of the     Write a column for a journal                10
   acutely ill adult population                            article in a local newsletter
                                                           or aaCN chapter newsletter                  3
 • address clinical knowledge, skills and abilities
   utilized by adult aCNPs                                 Original research article (peer reviewed)   30

                                                                                                       2 points / 10
these programs need not be approved by the american        textbook or chapter editor
                                                                                                       pages (max 30)
association of Critical-Care Nurses and may be offered
by hospitals, professional associations or independent     textbook author less than 300 pages         30
education groups. Home study or self-study programs
from professional journals and other sources that grant    textbook author more than 300 pages         60
contact hours apply to this category.
                                                           Professionally authored multimedia aids     15

If an academic Credit Course specific to the adult         Research abstract                           5
acute care population is completed, CEs points can
be accumulated in this category. Fifteen (15) CE points    Journal article (peer reviewed)             20
may be counted for each credit. For example, an
                                                           Journal reviewer
applicable 3-credit course would be worth 45 CE            (articles or book chapters)                 5
points.
                                                           Book reviews                                5
B. Continuing Education Programs Not Granting
                                                           unpublished master’s thesis
Contact Hours
                                                           or equivalent final project                 30
Includes aaCN chapter programs, hospital inservices,
                                                           Doctoral dissertation
workshops, study modules, etc. May account for only        or equivalent final project                 45
25 of the 75 required CE points.
                                                                                                       5 points per board
                                                           service on editorial boards
                                                                                                       per year

                                                                                                                Continued




                                                                                                                            7
                                 Ce renewal Points Program (CONtINuED)

Category II - Optional Activities (cont’d)                              C. Preceptorship or Volunteer Activities

B. Professional Presentations                                           Participating in activities/teams/committees that solve
Encompasses the certificant’s participation as an                       or prevent complex problems or improve care, across
instructor delivering content related to the acutely ill                multiple departments, settings, facilities or regions
adult population to nurses, other healthcare                            such as spearheading a major patient care improve-
professionals or the public. see aCNPC test plan for                    ment; and leading an interdisciplinary team to solve a
acceptable topics. the presentation must be delivered                   problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 pts
within a structured framework of teaching/learning.                                                                                             per year

a presentation includes a seminar, in-service,                          NOTE: activities regularly completed as the focus of
clinical conference, patient/family education program,                  employment may not be counted. For example, as one
consumer education program, aaCN chapter educa-                         of your hospital’s acute care NP you are automatically
tional activities and/or presenting an original paper                   assigned to the rapid response team you may not
or poster. the participation may be as a primary                        count this participation.
instructor, member of a team, guest lecturer, panel
participant, etc. No credit is given for repeat presenta-               Participation in leadership responsibilities or commit-
tions of the same content . . . . . . . . . . . . . . . . . . . 6 pts   tee involvement on a chapter/regional level . . . . 10 pts
                               per hour of lecture given                                                per committee per year

If the program is co-taught, the number of points to be                 Leadership responsibilities or committee involvement
awarded is determined by dividing points by the                         in professional, governmental or health related
number of instructors.                                                  organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 pts
                                                                                                                  per committee per year
NOTE: activities regularly completed as the focus of
employment may not be counted. For example, if you                      Preceptorship/mentorship – a minimum of 80 hours
regularly teach in your hospital’s orientation program,                 per year of preceptorship activity must be obtained in
you may not count those presentations; however, you                     order for points to be granted . . . . . . . . . . . . . . . . 10 pts
may count presentations given on a newly researched                                                                                per year
topic for NtI or for your chapter, etc.
                                                                        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 for precepting or teaching
                                                                        undergraduate students.



                                       maintaining aCnPC CertifiCation

Once the aCNPC credential is obtained, to maintain aCNPC certification you must complete one of three
options prior to your certification expiration date. For complete details, refer to the ACNPC Renewal
Handbook available at www.certcorp.org > Documents and Handbooks.




8
                         aCnPC By endorsement aPPliCation fees

                              Option 1 - No Clinical Hours or CE Renewal Points
                                  Expiration date will be same as ANCC certification.
                               aaCN Members                            No Fee

                               Nonmembers                              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 out approximately 90 days prior to the certification expiration date. You are responsible
for notifying aaCN Certification Corporation should your name and/or address change at any time before or 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 email address changes; you may update your profile:
  • online at www.aacn.org/myaccount,
  • email info@aacn.org, or
  • call aaCN Customer Care at (800) 899-2226

the following changes must be made by calling aaCN Customer Care at (800) 899-2226
  • 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
10
                                                                                                                                                                       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:                                                        APRN/RN LICENSE:
                                Number              Exp. Date                                                 Number                   state                   Exp. Date
NAME:
                                Last                                        First                                 MI                               Maiden
HOME ADDRESS:
                                                                                                           City                   state                  ZIP
EMPLOYER NAME:                                                                                   BUSINESS PHONE:


EMPLOYER ADDRESS:
                                                                                                           City                   state                  ZIP
PREFERRED EMAIL:                                                                                 HOME PHONE:


2. DEMOGRAPHIC INFORMATION (Check one box in each category.) Information used for statistical purposes only.
Primary Area Employed                    Primary Position Held                          Is English your first language?              Primary Type of Facility in Which
  acute Hemodialysis unit (21)             academic Faculty (07)                                                                     Employed
  Burn unit (13)                           acute Care Nurse Practitioner (09)              Yes        No                                  College/university (08)
  Cardiac Rehabilitation (26)              administrator/Vice President (43)                                                              Community Hospital (Nonprofit) (01)
  Cardiac surgery/OR (36)                  Bedside/staff Nurse (01)                     Did you graduate from nursing school in           Community Hospital (Profit) (02)
  Cardiovascular/surgical ICu (09)         Clinical Director (04)                       a country other than the U.S.?                    County Hospital (07)
  Catheterization Lab (22)                 Clinical Nurse specialist (08)                                                                 HMO/Managed Care (12)
  Combined adult/Pediatric ICu(23)         Corporate Executive (11)                        Yes        No                                  Home Health (13)
  Combined ICu/CCu (01)                    Elected Official (12)                                                                          Military/government Hospital (04)
                                                                                        If yes, which country?
  Coronary Care unit (03)                  Inservice/staff Devel. Instructor (06)                                                         Private Industry (11)
  Corporate Industry (24)                  Legal Nurse Consultant (39)                                                                    Registry (10)
  Critical Care transport/Flight (17)      Manager (03)                                 _______________________________                   self-Employed (09)
  Emergency Department (12)                Nurse anesthetist (02)                                                                         travel Nurse (15)
  general Medical/surgical Floor (18)      Nurse Educator (46)                          What year did you start practicing                university Medical Center (03)
  Home Care (25)                           Nurse Midwife (13)                                                                             Other – specify below
                                                                                        nursing in the U.S.?
  Intensive Care unit (02)                 Nurse Practitioner (05)
  Interventional Cardiology (31)           Pharmacist (14)
                                                                                        ________________________________                  ____________________ (99)
  Long-term Care (27)                      Physician (16)
  Medical Cardiology (34)                  Physician assistant (17)
                                                                                        Ethnicity                                    Number of beds in Institution
  Medical ICu (04)                         Researcher (18)
  Medical surgical ICu (35)                Respiratory therapist (19)                      african-american (02)
  Neonatal ICu (06)                        social Worker (20)                              asian (05)                                __________________________________
  Neuro./Neurosurgical ICu (10)            unit Coordinator (22)                           Hispanic/Latino (03)
                                                                                           Native american (04)                      Years experience in nursing
  Oncology unit (19)                       Other - specify below
  Operating Room (15)                                                                      Pacific Islander (06)
  Outpatient Clinic (29)                                                                   White/Non-Hispanic (01)                   __________________________________
                                           ____________________ (99)                       Other – specify below
  Pediatric ICu (05)
                                                                                                                                     Years experience in acute care nursing
  Private Practice (32)                  Highest Nursing Degree
  Progressive Care unit (16)               associate’s Degree                             ____________________ (99)
  Recovery Room/PaCu (14)                  Bachelor’s Degree                                                                         __________________________________
  Respiratory ICu (08)                     Diploma                                      Have you completed Red Cross Disaster
  stepdown unit (30)                       Doctorate                                    Recovery training?                           Date of Birth (Month/Day/Year)
  subacute Care (28)                       Master’s Degree
  surgical ICu (07)
                                                                                           Yes (01)        No (02)
  tele-ICu (37)                                                                                                                      __________________________________
  telemetry (20)
                                                                                                                                     Gender
  trauma unit (11)
  Other – specify below
                                                                                                                                          Female      Male

 ____________________ (99)



                                                                                                                             Please complete page 2 of application.




    aPCaPW                                                                                                                                                     august 2012

                                 this application form may be photocopied and is available online at www.certcorp.org.                                                          11
                                                             FOR OPTION 1                                                              2 of 2

                               honor statement - aCnPC By endorsement
           For Adult ACNPs certified through ANCC who wish to endorse over to AACN with the same renewal period.
                            PLEASE PRINT CLEARLY. PROCESSING WILL BE DELAYED IF INCOMPLETE OR NOT LEGIBLE.

NAME:                                                                                   AACN CUSTOMER #:
                     Last                     First                     MI

3. HONOR STATEMENT
I hereby apply for aCNPC certification offered by aaCN Certification Corporation. 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 my aCNPC certification,
once approved, will be valid through the date my aNCC certification is due to expire, regardless of the date this application is signed.

LICENSURE: I possess a current unencumbered u.s. aPRN or RN license. My ___________________________________________ (state)
RN 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. I understand that I must notify aaCN Certification Corporation within 30 days if any restriction
is placed on my aPRN or RN license in the future.

AUDIT: I understand that information supplied is subject to audit, and failure to respond to a request for further information may be
sufficient cause for aaCN Certification Corporation to withhold certification, revoke certification or take other appropriate action.

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 the application and supporting documentation is true, complete, correct and is
made in good faith. I am aware that the information acquired in the certification process may be used for statistical purposes and for
evaluation of the certification program.

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

         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 of aPRN license (or RN license in states where aPRN licenses are not issued) or online printed version
          Copy of current aCNP certification (wallet card or certificate)
     submit (with payment, if applicable) to:
         AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656-4109. Or Fax to: (949) 362-2020.

                 NOTE: Allow 2 to 4 weeks from date received by AACN Certification Corporation for application processing.
                       Questions? Please visit www.certcorp.org, email certcorp@aacn.org or call us at (800) 899-2226.

                                                                                                                               august 2012

12                              this form may be photocopied and is also available online at www.certcorp.org.
                                                                                                                                      1 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.


1. REGISTRATION INFORMATION                 PLEASE PRINT CLEARLY. PROCESSING WILL BE DELAYED IF INCOMPLETE OR NOT LEGIBLE.
                                                                     .

AACN CUSTOMER:                                           APRN/RN LICENSE:
                         Number            Exp. Date                                 Number                state              Exp. Date
LEGAL NAME:
                         Last                                First                       MI                        Maiden
HOME ADDRESS:
                                                                                  City                state             ZIP
EMPLOYER NAME:                                                               BUSINESS PHONE:


EMPLOYER ADDRESS:
                                                                                  City                state             ZIP
PREFERRED EMAIL:                                                             HOME PHONE:


2. AACN MEMBERSHIP
   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                                                                  Membership Fee:
      3-year aaCN membership………………………….…………$200
                                                                                                                   $__________
                                                                                                                         +
3. ACNPC CERTIFICATION FEES: (subject to change without notice; check one box only)                              Certification Fee:
        $200 ACNPC Certification by Endorsement             $305 ACNPC Certification by Endorsement                     $__________
             AACN Member                                         Nonmember
                                                                                                                              =
                                                                                                                       Total Payment:
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

    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.




                                                                                          Please complete pages 2 and 3 of application.




    aPCaPW                                                                                                                    august 2012

                          this application form may be photocopied and is available online at www.certcorp.org.                             13
                                                                                                                                                                 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 only.
Primary Area Employed                     Primary Position Held                       Is English your first language?           Primary Type of Facility in Which
   acute Hemodialysis unit (21)              academic Faculty (07)                                                              Employed
   Burn unit (13)                            acute Care Nurse Practitioner (09)          Yes        No                             College/university (08)
   Cardiac Rehabilitation (26)               administrator/Vice President (43)                                                     Community Hospital (Nonprofit) (01)
   Cardiac surgery/OR (36)                   Bedside/staff Nurse (01)                 Did you graduate from nursing school in      Community Hospital (Profit) (02)
   Cardiovascular/surgical ICu (09)          Clinical Director (04)                   a country other than the U.S.?               County Hospital (07)
   Catheterization Lab (22)                  Clinical Nurse specialist (08)                                                        HMO/Managed Care (12)
   Combined adult/Pediatric ICu(23)          Corporate Executive (11)                    Yes        No                             Home Health (13)
   Combined ICu/CCu (01)                     Elected Official (12)                                                                 Military/government Hospital (04)
   Coronary Care unit (03)                   Inservice/staff Devel. Instructor (06)   If yes, which country?                       Private Industry (11)
   Corporate Industry (24)                   Legal Nurse Consultant (39)                                                           Registry (10)
   Critical Care transport/Flight (17)       Manager (03)                             _______________________________              self-Employed (09)
   Emergency Department (12)                 Nurse anesthetist (02)                                                                travel Nurse (15)
   general Medical/surgical Floor (18)       Nurse Educator (46)                                                                   university Medical Center (03)
                                                                                      What year did you start practicing
   Home Care (25)                            Nurse Midwife (13)                                                                    Other – specify below
   Intensive Care unit (02)                  Nurse Practitioner (05)                  nursing in the U.S.?
   Interventional Cardiology (31)            Pharmacist (14)
                                                                                      ________________________________            ____________________ (99)
   Long-term Care (27)                       Physician (16)
   Medical Cardiology (34)                   Physician assistant (17)
                                                                                      Ethnicity                                 Number of beds in Institution
   Medical ICu (04)                          Researcher (18)
   Medical surgical ICu (35)                 Respiratory therapist (19)                  african-american (02)
   Neonatal ICu (06)                         social Worker (20)                          asian (05)                             __________________________________
   Neuro./Neurosurgical ICu (10)             unit Coordinator (22)                       Hispanic/Latino (03)
                                                                                         Native american (04)                   Years experience in nursing
   Oncology unit (19)                        Other - specify below
   Operating Room (15)                                                                   Pacific Islander (06)
   Outpatient Clinic (29)                                                                White/Non-Hispanic (01)                __________________________________
                                            ____________________ (99)
   Pediatric ICu (05)                                                                    Other – specify below
                                                                                                                                Years experience in acute care nursing
   Private Practice (32)                  Highest Nursing Degree
   Progressive Care unit (16)                associate’s Degree                         ____________________ (99)
   Recovery Room/PaCu (14)                   Bachelor’s Degree                                                                  __________________________________
   Respiratory ICu (08)                      Diploma
   stepdown unit (30)                                                                 Have you completed Red Cross Disaster
                                             Doctorate                                Recovery training?                        Date of Birth (Month/Day/Year)
   subacute Care (28)                        Master’s Degree
   surgical ICu (07)
   tele-ICu (37)                                                                         Yes (01)        No (02)                __________________________________
   telemetry (20)
                                                                                                                                Gender
   trauma unit (11)
   Other – specify below
                                                                                                                                  Female       Male

  ____________________ (99)




6. COMPLETE AND SIGN HONOR STATEMENT ON NExT PAGE

7. SUBMIT APPLICATION AND DOCUMENTATION
     attach the following to this application:
                 Copy of aPRN license (or RN license in states where aPRN licenses are not issued) or online printed version
                 Copy of current aCNP certification (wallet card or certificate)
     submit with payment to: AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656-4109. Or Fax to: (949) 362-2020.


                   NOTE: Allow 2 to 4 weeks from date received by AACN Certification Corporation for application processing.

                         Questions? Please visit www.certcorp.org, email certcorp@aacn.org or call us at (800) 899-2226.




                                                                                                                                                      august 2012
                                 Did you include copies of your RN or aPRN license, aCNP certification and fee payment?
14
                                                                                                                                     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. PROCEssINg WILL BE DELaYED IF INCOMPLEtE OR NOt LEgIBLE.



NAME:                                                                               AACN CUSTOMER #:
                    Last                       First                    MI


I hereby apply for aCNPC certification offered by aaCN Certification Corporation. I have read and understand 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 Credential-
ing Center (aNCC).

LICENSURE: I possess a current unencumbered u.s. aPRN or RN license. My ________________________________________ (state)
RN 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. I understand that I must notify aaCN Certification Corporation within 30 days if any
restriction is placed on my aPRN or RN license in the future.

PRACTICE: I understand that a significant component of aPRN practice focuses on direct care of individuals. During the last 5-year
certification period I have completed 1,000 hours within the u.s. as an aPRN in the direct care of acutely ill adult patients in the role
of the acute care nurse practitioner.

PRACTICE VERIFICATION: Following is the contact information of my clinical director or a professional associate (RN or physician)
who can verify my clinical hour eligibility:

VERIFIER’S NAME:                                                         FACILITY NAME:
                            Last                   First

VERIFIER’S PHONE NUMBER:                                          VERIFIER’S EMAIL ADDRESS:

You may not list yourself or a relative as your verifier.

CONTINUING EDUCATION: I have completed 150 CE Renewal Points in the last 5 years, as defined in the aCNPC CE Renewal Points
Program.

AUDIT: I understand that information supplied is subject to audit, and failure to respond to a request for further information may be
sufficient cause for aaCN Certification Corporation to bar me from the exam, invalidate the results of my exam, withhold certification,
revoke certification or take other appropriate action.

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 the application and all supporting documentation is true, complete, correct
and is made in good faith. I am aware that the information acquired in the certification process may be used for statistical purposes
and for evaluation of the certification program.


Applicant’s Signature:                                                                                     Date:

          Please allow 2 to 4 weeks from date received by AACN Certification Corporation for processing of your application. 

   august 2012

                                this form may be photocopied and is also available online at www.certcorp.org.                              15
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