Nurse Practitioner Form 2c - Verification Of Pharmacotherapeutics Course (Page 2 of 2) in pdf

Nurse Practitioner Form 2c - Verification Of Pharmacotherapeutics Course Page 2

Section II: Verification of Completion of Pharmacotherapeutics Course

Instructions to School/Institution/Professional Association: Please complete Section II and return both pages of this form directly to the

New York State Education Department at the address at the end of this form. This form will not be accepted if returned by the applicant

or any other party.

It is hereby verified that: __________________________________________________________________________________________

(Section I, item 6)

has completed pharmacotherapeutics instruction in drug management of clients in the nurse practitioner's specialty area of

_____________________________________________________________________________________________________________ .

This course was

part of nurse practitioner program, or

supplementary course.

The inclusive date(s) of the course were: _______ /_______ /_______ and _______ / _______ / _______.

mo.

day

yr.

mo.

day

yr.

The length of the course was: _________________ or _________________.

(Semester hours)

(Clock hours)

In this course, did the individual named receive instruction in New York State and Federal laws relating to prescriptions and record

keeping?

Yes

Attestation

I hereby attest that to the best of my knowledge and belief the information in Section II is an accurate record of the completion of a course in

pharmacotherapeutics by the individual named on this form.

Signature: ____________________________________________________________________

Date: _______ / _______ / _______

mo.

day

yr.

Print Name: __________________________________________________________________

Title or official position: __________________________________________________________

Institution: _____________________________________________________________________

Address: ______________________________________________________________________

(SEAL)

_______________________________________________________________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Nurse Practitioner Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Nurse Practitioner Form 2C, Page 2 of 2, (Rev. 3/09)

Nurse Practitioner Form 2c - Verification Of Pharmacotherapeutics Course Page 2