Certification Organization for the American Association of Critical-Care Nurses Verification of Bedside Hours for CCRN-E Renewal 3-Year CCRN-E Renewal Audit Period: ____________ – ____________ CERTIFICANT: This form must be completed by your supervisor or a professional colleague (RN or physician), confirming that you fulfilled the requirement of monitoring and caring for acutely and/or critically ill adult patients in a tele-ICU or in a combination of tele-ICU and direct bedside care for a minimum of 432 hours during the last 3-year certification period, with 144 of those hours accrued in the 12-month period prior to your scheduled renewal date. This form must contain contact information for your verifier. VERIFIER: Please complete and sign the below verification and return this form to the certificant to include in their audit packet. I, ___________________________________, verify that ___________________________________ has fulfilled (printed name of verifier) (printed name of certificant) the requirement of monitoring and caring for acutely and/or critically ill adult patients in a tele-ICU or in a combination of tele-ICU and direct bedside care for a minimum of 432 hours during the last 3-year certification period, with 144 of those hours accrued in the 12-month period prior to their scheduled renewal date. To the best of my knowledge, the information I am providing is accurate and submitted in good faith. I understand that I may be contacted by AACN to validate the information provided. _________________________________________ Verifier’s Title _________________________________________ Verifier’s Signature Date _________________________________________ Hospital Name _________________________________________ Hospital City & State _________________________________________ Verifier’s Business Email _________________________________________ Verifier’s Business Phone All fields must be completed. 101 Columbia Aliso Viejo, CA 92656 (800) 899-2226 www.certcorp.org 10-2014
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