Read CCHT Recertification Application Booklet text version

Recertification Examination Application

Nephrology Nursing Certification Commission

5

Recertification Application

CCHT Recertification Eligibility Criteria 1. Certificant must be a Certified Clinical Hemodialysis Technician (CCHT). 2. A certificant must have a minimum of 3000 hours of work experience as a hemodialysis technician within the three (3) year certification period. 3. Continuing education must include thirty (30) hours of education relevant to the hemodialysis technician scope of practice in caring for patients requiring dialysis, and must be completed during the recertification period. CCHT Contact Hour Certificates Contact hour certificates must include the following information to be acceptable for recertification: · Name of attendee · Date of program · Name of program · Number of contact hours awarded · Accreditation statement if applicable (see page 3) It is not necessary to include copies of contact hour certificates with the recertification application, unless you have been notified that your application has been selected for an audit. CCHT Recertification Application Instructions 1. Make sure you meet all CCHT recertification eligibility requirements. 2. Complete the application in its entirety. 3. Record all contact hour information on the appropriate form(s). 4. Enclose appropriate fee made payable to NNCC. 5. Retain a copy of the recertification application and all contact hour certificates.

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Recertification Application

For office use only Number: Exam Date: Check #: Processor: Postmark: Amount:

Recertification Application

Application must be postmarked on or before certification expiration date to avoid a late fee. Please print or type all information requested. Incomplete or illegible applications will be returned to the certificant. Recertification fees and late fees are non-refundable. Application fee: $100

Last

$50 Late fee

Maiden

Check or money order

Charge my credit card Visa MC

First Middle

1. Name: _________________________________________________________________________________________ 2. Expiration date of current certification: ____________________________________________________________ 3. Name as it should appear on your wallet card:_______________________________________________________ 4. Last 4 digits of social security number _____________ E-mail____________________________________________ 5. Home/mailing address ____________________________________________________________________________

Street/P Box .O. City State Zip

6. Home phone ____________________________________ Work phone ____________________________________ 7. Has your address changed in the past three (3) years? Yes No 8. State registration if applicable: State ______ Reg # ________________________ Exp date __________________ 9. Have you been employed at least 3,000 hours as a Hemodialysis Technician in the last three (3) years? yes no 10. Total years of experience as a Hemodialysis Technician _______ 11. Highest level of education completed: High School Diploma/GED Associate degree Master's degree Doctorate 12. Record current recertification period dates here: See page 7, number 3. Bachelor's Degree LPN/LVN Start: End: month _____ day _____ year _____ month _____ day _____ year _____

Note these dates when completing contact hour form.

Credit Card Authorization Form

The NNCC accepts only Visa and MasterCard credit cards.

Name: _______________________________________________ Address: (as it appears on your credit card statement) ____________________________________________________ City: ________________________________________________ State: ______ Zip: __________ Country:____________________ Home telephone: ______________________________________ Work telephone: ______________________________________ Charge my: Visa MasterCard the amount of $________

Card number:____________________________CVV__________ Expiration date: _______________________________________ _____________________________________________________

Authorized Signature

Revised 1/11

9

Recertification Application 13. Verification of Employment

I hereby verify that this individual has been employed as a hemodialysis patient care technician for 3,000 hours within the last three (3) years. Signature of current supervisor______________________________________________ Date _________________ Title of supervisor _____________________________________________________________________________ Supervisor's E-mail ___________________________________________________________________________ Institution _______________________________________________________ Phone ______________________ Business address _____________________________________________________________________________ I hereby attest that I have read, understand, and agree to abide by the policies stated on the NNCC Web site and in the most current recertification application booklet. I hereby apply for renewal of certification and verify that all information is correct. Legal Signature ______________________________________________________Date _____________

Did You Remember to

Complete the recertification application in its entirety? Record all contact hour information on the contact hour form? Include the appropriate fee? Have your employer complete his/her portion of the application in its entirety? Sign and date the application? Keep a copy of the application and all supporting documents?

Mail completed application to: NNCC East Holly Avenue Box 56 Pitman, NJ 08071-0056

Revised 1/11

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CCHT Form 1 Contact Hour Form

Title of Program

(see requirements on page 7)

Date Completed

Number of Contact Hours Awarded

Recertification Application

11

Please retain all contact hour certificates in your personal file in the event of an audit. You may make copies of this form if additional space is needed.

CCHT Form 2 Contact Hour Form

Title of Program

(see requirements on page 7)

Date Completed

Number of Contact Hours Awarded

Recertification Application

12

Please retain all contact hour certificates in your personal file in the event of an audit. You may make copies of this form if additional space is needed.

Information

CCHT Recertification Application Booklet

6 pages

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