Get Verification Of Post-graduate Supervised Experience - Dopl Utah

Filling out the Verification Of Post-Graduate Supervised Experience form is a crucial step for applicants seeking licensure as an Advanced Practice Registered Nurse (APRN) specializing in Psychiatric Mental Health Nursing in Utah. This guide provides clear and structured instructions on how to complete this form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the document and open it in the online editor.
2. Complete the applicant information section. Enter your full legal name, including first, middle, and last names. Provide your mailing address, including street or P.O. box, city, state, and zip code. Additionally, include your license number and state of issue.
3. Fill in the employment information. This section must be completed by your supervisor. They need to provide the name of the establishment, their own name, and their license number. Ensure the establishment's address, telephone number, city, state, and zip code are accurately filled out.
4. Your supervisor must enter their email address and the dates of your employment or supervision. These dates should be entered in MM/DD/YYYY format.
5. Indicate the total hours of supervised experience you completed in mental health therapy along with the hours of supervised clinical practice. This should reflect the actual time spent under supervision.
6. Have your supervisor describe your duties during this supervised experience to provide context to your role.
7. Answer the question regarding whether you and the supervisor worked at the same place of employment by selecting Yes or No. If the answer is No, provide a description of how supervision was conducted.
8. Your supervisor must certify the information provided by signing and dating the form. This step confirms that you have completed the required hours of post-graduate supervised experience as a W-2 employee of the establishment.
9. After ensuring all information is correct, save your changes. You will have options to download, print, or share the completed form as needed.

Complete your documents online to streamline the application process for licensure.