Shining Star Application Form

Component

President

Contact Person

Contact Address

Contact Work Phone

Contact Email

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Please verify that at least 25% of the component membership is CPAN® and/or CAPA® certified:

Number of component members as of February 1st

Number of CPAN^® and CAPA^® certified members as of February 1st

Percentage of component members who are certified

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NARRATIVE:

Please describe how your component has met the following criteria in the previous calendar year.

At least one scholarship has been awarded: for certification fees or recertification fees; or to a CPAN®/CAPA® certified nurse to attend an educational program;

At least one member of the component serves as a Certification Coach;

Information about CPAN® and CAPA® certification is published in each Component newsletter

CPAN and CAPA certification information is provided at every Component meeting;

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Optional: You may upload any supporting documentation from your component regarding the award criteria.

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