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Thursday, November 21, 2024   5:41 AM    |   58°F

Clinical Nurse Educator Academy Submission

Instructions

Upon completion of the Clinical Nurse Educator Academy program and final evaluation, please review the stipend eligibility criteria below. If you meet the criteria, please submit the required documentation for verification and enrollment into the grant. Upon verification, you will qualify for the respective stipends below as funds allow per grant year. Please submit scanned versions of your documents instead of photographs.

Stipend 1 Eligibility Criteria:

  1. All NCPD certificates of program completion (from Modules 1-5, NPACE if applicable, and your Final certificate)
  2. Unrestricted nursing license in at least 1 of the HHS region 6 states (Louisiana, Texas, Arkansas, New Mexico, Oklahoma)
  3. Verification of nursing practice within the HHS region 6 states (link to template - download to computer, fill out, and upload below)
  4. Submission of a signed W-9 (link to form - download to computer, fill out, and upload below)


First:
Middle:
Last:
E-Mail Address:


License Verification:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Nursing Practice:

 (.docx, .doc, and .pdf only, 1MB limit)

Signed W-9:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 1 certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 2 certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 3 certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 4 certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Final Program Certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 5 RN certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

Verification of Module 5 APRN certificate:

 (.docx, .doc, and .pdf only, 1MB limit)

I am a preceptor referred by the ANEW grant: