Nurse Peer Reviewer Qualification Form
Name
*
First Name
Last Name
Degrees held *A nursing degree at the level of baccalaureate or higher is required.*
*
Licenses and Certifications
*
ANA/SNA Membership (Yes, insert which state)
*
Example: RI, MA, NY
ANA/SNA Membership #
*
Mailing Address Preferred
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Number
*
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Employer Name
*
Department
*
Title, description of present position
*
Work Number
*
Please enter a valid phone number.
Employer Address
*
Source of knowledge of continuing nursing education:
*
Academic training
Experience
Orientation
Other
Please explain/describe the above:
*
Source of knowledge of ANCC Accreditation criteria:
*
Academic training
Experience
Orientation
Other
Have served as a Primary Nurse Planner for an Approved Provider Unit
Have submitted Individual Activity Applications as a Nurse Planner
Please explain/describe the above:
*
Upload your CV here
*
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The Professional Development Director will contact you once the Nurse Peer Reviewer Qualifications form is processed and approved by our Nurse Peer Review Leader.
Questions, please contact us at education@risna.org
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