Clinical Nurse Specialist Form 4 - Verification Of Experience - New York The State Education Department
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1
2Department Use Only
The University of the State of New York
Clinical Nurse Specialist
THE STATE EDUCATION DEPARTMENT
Approved
Office of the Professions
Form 4
Division of Professional Licensing Services
Date
Verification of Experience
(Use this form ONLY if you are following alternative requirements for a certificate prior to
September 15, 2017.)
Applicant Instructions
1.
Complete Section I. In item 4, enter your name exactly as it appears on your Application for a Certificate (Form 1). Be sure to sign and
date item 7.
2.
Send the entire form to the clinical supervisor who has been responsible for supervising the work for which you are seeking credit and
ask her/him to complete Section II and send both pages of the form directly to the Office of the Professions at the address at the end of
this form. This form will not be accepted if submitted by the applicant or any other party.
3.
A separate form 4 must be provided by each supervisor with whom you worked while acquiring the required experience.
Section I: Applicant Information
1.
1
Social Security Number
2.
2
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3.
New York State Registered Professional Nurse License Number
3
4
3.
Print Name as It Appears on Your Application for a Clinical Nurse Specialist Certificate (Form 1)
Last
First
Middle
5
6.
Clinical nurse specialist specialty area for which you are applying: _______________________________________________________
6
6.
Name of clinical supervisor: ______________________________________________________________________________________
7
7.
I authorize the clinical supervisor named above to provide any information requested, including the information requested on this form,
to the New York State Education Department.
_______________________________________________________________________________
________ / ________ / ________
Applicant’s Signature
mo.
day
yr.
Section II: Verification of Experience - To be completed by the Clinical Supervisor
The individual named above is seeking certification as a clinical nurse specialist in the specialty area named in (5) above*.
*Note: To qualify for certification as a clinical nurse specialist, the applicant must have completed after January 1, 2011 at
least three thousand hours of clinical practice in a clinical nurse specialty area in a general hospital pursuant to Article 28 of
the Public Health Law in New York State.
Please complete Section II, sign and date the certification and return both pages of this form directly to the Office of the Professions at the
address at the end of the form.
Name of General Hospital: __________________________________________________________________________________________
Address: ________________________________________________________________________________________________________
In what capacity was the applicant employed? ___________________________________________________________________________
Full time
Part time
Inclusive dates (note interruptions): From ______ / ______ / ______ to ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
Number of hours of clinical practice in clinical nurse specialist related field: ________________________________
Type of clinical nurse specialist experience (check one): Adult Health
Oncology
Pediatrics
Psychiatry
Clinical Nurse Specialist Form 4, Page 1 of 2, Rev. 10/14
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