Northeast MSD Continuing Education Peer Reviewer Qualification Form

CONTINUING EDUCATION NURSE PEER REVIEWER QUALIFICATIONS FORM

Alabama, Hawai'i and Vermont
Date*

MonthDayYear
Name*

First NameLast Name
License Expiration Date*
License Number and State*
Certifications
Degrees held *A nursing degree at the level of baccalaureate or higher is required.*

ADDiplomaBSNMastersDoctorate
Current Member of ANA/SNA (Select State of Membership)*

Hawai'iVermontAlabamaOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Information*

Employer Name

Street Address

CityState / Province

Postal / Zip CodeCountry
Position/Title*
E-mail*
Home Number

Area CodePhone Number
Cellular Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Source of knowledge of continuing nursing education*

Academic trainingExperienceOrientationOther
Please explain/describe the above:*
Source of knowledge of ANCC Accreditation criteria:*

Academic trainingExperienceOrientationOtherHave served as Primary Nurse Planner for an Approved Provider UnitHave submitted Individual Activity Applications as a Nurse Planner
Please explain/describe the above:*
Please provide a brief explanation why you would like to be a Nurse Peer Reviewer*
The Director of Professional Development will contact you once your Peer Reviewer Qualifications Form has been processed and approved by the Accredited Approver Program Director.
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CONTINUING EDUCATION NURSE PEER REVIEWER QUALIFICATIONS FORM