Get Affidavit Of Work Hours - Kansas State Board Of Nursing - Ksbn

This guide provides step-by-step instructions for completing the Affidavit Of Work Hours required by the Kansas State Board of Nursing. Following these steps will help ensure that you accurately fill out the form online and submit it correctly.

Follow the steps to complete the affidavit with ease.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the name of the applicant in the designated field. This should be the individual whose work hours are being reported.
3. Input the Social Security number of the applicant accurately in the corresponding section.
4. Fill in the name of the employer who is completing the affidavit. This can be the employer or an authorized representative.
5. Provide the complete address of the employer, ensuring all details such as street, city, and ZIP code are included.
6. Specify the dates of employment during which the applicant worked. This is essential for validating the hours reported.
7. Certify the applicant's work hours by selecting the applicable specialty from the provided options. Check the box for: '1000 hours as a Registered Nurse applying for endorsement', '1000 hours as a Nurse Practitioner', '1000 hours as a Clinical Nurse Specialist', '1000 hours as a Registered Nurse Anesthetist', or '1000 hours as a Nurse Midwife' as appropriate.
8. Have the employer or authorized representative print their name and signature in the specified locations.
9. Fill in the position title of the person signing the affidavit, along with the date of completion.
10. Include the phone number of the employer or authorized representative in the designated field.
11. The affidavit must be signed and dated by a notary public. Make sure to leave space for notary information and seal.
12. Review all entries for accuracy and completeness before finalizing the form.
13. Once the form is completed, you can save changes, download, print, or share the form as needed.

Complete your Affidavit Of Work Hours online today to ensure a smooth submission process.