Registered Physician Assistant Form 2 - Certification Of Professional Education (Page 2 of 2) in pdf

Section II: Certification Of Professional Education

INSTRUCTIONS TO INSTITUTION REGISTRAR:

Complete Part A or Part B to document the applicant’s education.

Complete Part C (Certification) and return both pages of this form directly to the Office of the Professions at the address at the end of this form.

Do not return this form to the applicant.

Part A

–Programs Registered By New York State As Licensure Qualifying Or Accredited By The Accreditation Review Commission On Education

For The Physician Assistant (ARC-PA) At The Time The Applicant Completed The Program.

To be completed only by those schools at which the applicant completed a physician assistant program registered by the New York State Education

Department as licensure qualifying or accredited by the ARC-PA.

It is certified that ___________________________________________________________________________________________________________:

(Name of applicant – See Section I, item 5)

was awarded the credential of ____________________________________________________________ on ________ / ________ / ________

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day

yr.

(Title of credential)

on ________ / ________ / ________

this institution determined that the above-named student met all requirements for the credential and the

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day

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institution has agreed to award the credential of ____________________________________________________________________________.

(Title of credential)

Part B – All Other Programs.

An official transcript or marksheet giving courses completed by year and grades and a syllabus of the course of studies completed must be attached.

(1) Date of applicant's entrance, and either the applicant’s date of completion of studies or withdrawal from the school:

Entrance date: _____ / _____ / _____

Completion date: _____ / _____ / _____

Withdrawal date: _____ / _____ / _____

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day

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(2) Did the student complete at least 32 semester hours of classroom work?

Yes

If “No”, number of clock hours: ____________

(2) Did the student complete 1,600 clock hours of supervised clinical training?

Yes

If “No”, number of clock hours: ____________

(3) Credential Awarded: ______________________________________________________________________________________________________

(4) Date credential awarded: _____ / _____ / _____

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Name of accrediting body or official organization that recognizes this program: ________________________________________________________

Address of accrediting body or organization that recognizes the program: ____________________________________________________________

_______________________________________________________________________________________________________________________

Part C - Certification

I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the educational record of the individual

named on this form.

Signature of Registrar ______________________________________________________________ Date _______ / _______ / _______

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Type or print name ________________________________________________________________

Title or official position _____________________________________________________________

Institution ________________________________________________________________________

Address _________________________________________________________________________

(INSTITUTION SEAL)

__________________________________________________________________________

Telephone number ______________________________ Fax _______________________________

E-mail ____________________________________________________________________________

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

89 Washington Avenue, Albany, NY 12234-1000.

Registered Physician Assistant Form 2, Page 2 of 2, Rev. 05/05