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I am applying to serve on the Subject Matter Expert Registry. I am interested being a: (check all that apply) Content developer Peer reviewer Presenter
In which areas are you a subject matter expert?
Which of the following qualifications do you meet? Currently certified in specialty of interest through ANCC Have teaching or speaking experience Have not served on a 1) panel, 2) as an item writer or 3) in any other related capacity with the ANCC Certification department in the past three years
Other speciality areas: __________________________________________________________________
1. GENERAL INFORMATION
Nurse Practitioners Adult-Gerontology Acute Care NP Adult-Gerontology Primary Care NP Adult Psychiatric–Mental Health NP Family NP Gerontological NP Pediatric NP
Clinical Nurse Specialists Adult-Gerontology CNS Adult Psychiatric–Mental Health CNS
Specialties Cardiac-Vascular Nursing Gerontological Nursing Informatics Nursing Medical-Surgical Nursing Nurse Executive Nurse Executive, Advanced Nursing Case Management Nursing Professional Development Pediatric Nursing Psychiatric–Mental Health Nursing
FAMILY NURSE PRACTITIONER
EXAM PREP AND CONTINUING EDUCATION
NURSING KNOWLEDGE CENTER
WORKSHOPS WEBINARS CONSULTATION CONFERENCES PUBLICATIONS
1. GENERAL INFORMATION • CONT.
Please use your legal name on the application.
Ms. Miss Mrs. Mr. Dr. Other: ____________________________
Last Name First Name MI
Credentials [Academic Degree, Licensure/Stated Designation, Board Certification (e.g., BSN, RN-BC)]
Current RN License # State Issued Expiration Date Years as an RN
Home Address
City State Zip/Postal
Preferred Phone Cell Home Work Alternate Phone Cell Home Work
Preferred Email Alternate Email
2. CURRENT EMPLOYMENT INFORMATION
Employer Name
Position Title Dates of Employment
Employer Address
City State Zip/Postal
Work Phone Ext. Work Fax
Work Email
3. PART 1 • PRIMARY EMPLOYMENT – GEOGRAPHIC SETTING
Geographical setting of the facility at which you practice: Rural- population (< 2,500) Town- population (2,500—49,999) City- population (50,000—249,999) Metropolitan- population (250,000—999,999) Greater Metropolitan (>999,999)
6. STAFF DEVELOPMENT/CLINICAL EDUCATOR (includes adjunct faculty)
7. CLINICAL PRACTICE
8. STATEMENT OF UNDERSTANDING FOR SUBJECT MATTER EXPERT APPLICANTS
Are you primarily employed in staff development or as a clinical educator? Yes No
Do you spend at least 50% of your professional time teaching in the role, population, and specialty of the certification in which you are seeking appointment? Yes No
Are you also currently in clinical practice? Yes No
If yes, what percentage of your professional time do you spend in clinical practice? <25% 25–50% <50%
Are you currently in clinical practice? Yes No
Do you spend at least 50% of your professional time engaged in clinical practice in the role, population, and specialty of the certification area in which you are seeking appointment? Yes No
If selected and appointed, I agree to serve:
Signature* Date
*Your typed name is sufficient as a signature. Remember to include with the application your resume, job description, letter of recommendation, and, if self-employed, a letter describing your professional responsibilities and a statement of commitment and ability to participate on the panel.
Certification through ANCC is only required if you are applying to become a subject matter expert for educational products and services related to ANCC certification exam preparation. Certification through another nationally recognized certifying body, related professional work experience or a combination of both will be considered for all other Nursing Knowledge Center (NKC) educational programs. Selected subject matter experts for individual credentialing education programs will be ineligible to serve on any ANCC panel that is related to exam development for a period of 3 years.
