Academic Records Form Nurses

My current name First (given) name Middle name Last (family / surname) name Name of school I attended I attended between the dates of Month Year and Month Year My birth date Month Day Year My name when I attended this school First (given) name Middle name Last (family / surname) name My other names My CGFNS ID number (if known) Applicant signature My current mailing address Address My order number (if known) Address City State / Province Post / Zip code Country Telephone number (include country code and area code) Fax number (include country code and area code) Email address.

FOR SCHOOL TO COMPLETE Dear Registrar: Please complete this section of the form and send it to CGFNS along with the above applicant’s academic records/transcripts listing the courses taken, hours of study and grades earned, accompanied by a certified English translation. 1. Applicant name 2. In what language was the applicant instructed? Applicant’s birth date / / Month Day Year 3. What was the textbook language for the applicant’s program/course of study? 4. Program type (e. g. , diploma, baccalaureate) 5. Attendance dates Month Year Course of study Did applicant complete program ?

Month to Year n Yes n No 6. School name 7. School address SEAL OR STAMP Address Post / Zip code City State / Province Country Continued on following page © Copyright 2011 CGFNS International. Revised May 2011. Request for Academic Records/Transcripts FOR SCHOOL TO COMPLETE, page 2 NURSES 8. School telephone 9. School email address 10. Is this school accredited or government approved? By whom? Is this educational program accredited or government approved? By whom? n Yes n No School fax School web address Date accredited or approved n Yes n No Date accredited or approved.

Month / Day / Year Month / Day / Year I hereby attest that the enclosed academic records/transcripts accurately states the courses taken, hours of study and grades received for this applicant. 11. Registrar signature Do not print, sign entire name. School seal or stamp must cover signature. Print name SEAL OR STAMP Date Month / Day / Year Title In addition to attaching a copy of the academic records/transcripts, please provide specific hours of theoretical instruction and hours of clinical practice for the subject areas listed below.

Please DO NOT combine subject areas. If they are combined in your curriculum, please estimate the hours of theoretical instruction and hours of clinical practice in each subject area. Both the completed form and educational academic records/ transcripts must be sent directly to CGFNS. All documents must be in English. Theoretical Lab/Ward hours* Clinical practice hours Theoretical instruction hours* Subject Care of the adult — Medical nursing Care of the adult — Surgical nursing Maternal/Infant nursing (excluding gynecology) Subject.

Art English Foreign language History Music Philosophy Religion Speech TOTAL NURSING Gynecology Nursing care of children Psychiatric/Mental health nursing (excluding neurology) Neurology Community health/Public nursing Gerontology/Geriatric nursing Mental health concepts Long-term care nursing Acute care nursing Theory Lab SOCIAL AND BEHAVIORAL SCIENCES Physical assessment HUMANITIES Anthropology Archaeology Economics Human geography Political science Psychology Sociology TOTAL SCIENCE RELATED TO GENERAL SCIENCE Anatomy and Physiology Microbiology Pharmacology Nutrition Chemistry Physics.

* Includes classroom education, laboratory and planned clinical conferences (ward teaching) hours. CGFNS must have the breakdown of theoretical instruction hours and applicable clinical practice hours for all of the subjects. Please send this document and academic records/transcripts, in English, in an envelope with your seal or stamp over the flap after sealing. Send via airmail to : CGFNS International, 3600 Market Street, Suite 400, Philadelphia, PA 19104-2651 USA © Copyright 2011 CGFNS International. Revised May 2011.

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