Form Aprn - Certifying Org Verif Form - 2016
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12016 Verification Form for
Organizations Certifying Certified Nurse Midwives (CNMs), Certified Nurse
Practitioners (CNPs), Clinical Nurse Specialists (CNSs), and Certified Registered
Nurse Anesthetists (CRNAs)
Section 4723.46 (A) of the Ohio Revised Code sets out the requirements below for certifying
organizations to be recognized and approved by the Board for CNMs, CNPs, CNSs, and CRNAs
applying for approval to practice.
Please complete and return this approval form to the Board’s APRN Unit at the address above; by
fax at (614) 466-0388; or by e-mail to lrobinson@nursing.ohio.gov, no later than October 13,
2015. If sending by e-mail or fax, please follow-up with a hard copy.
1
Is national in the scope of its credentialing.
YES
NO
2
Has an educational requirement beyond that required for registered nurse
licensure.
YES
NO
3
Has practice requirements beyond that required for registered nurse licensure.
YES
NO
4
Has testing requirements beyond those required for registered nurse licensure that
measure the theoretical and clinical content of a nursing specialty, are developed in
accordance with accepted standards of validity and reliability, and are open to
registered nurses who have successfully completed the educational program
YES
NO
required by the organization.
5
Issues certificates to the following (check all that apply):
! Certified Nurse Midwives
! Certified Nurse Practitioners
! Clinical Nurse Specialists
YES
NO
! Certified Registered Nurse Anesthetists
6
Periodically reviews the qualifications of the following (check all that apply):
! Certified Nurse Midwives
! Certified Nurse Practitioners
! Clinical Nurse Specialists
YES
NO
! Certified Registered Nurse Anesthetists
Signature
_____________________________________________________________
Name (print) _____________________________________________________________
Title
_____________________________________________________________
Organization (full title) _____________________________________________________
Telephone Number ___________________ E-Mail Address ________________________
Date
____________________________________________________________________
2015 APRN
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