Follow the steps to fill out the application with ease.

1. Press the ‘Get Form’ button to access the application and open it in the editor.
2. In the first section, enter your name as the applicant and ensure to include your complete Alabama RN license number. Provide your daytime telephone number and email address for contact purposes.
3. Proceed to the procedure request section. Carefully describe the procedure name, request date, and purpose in detail, addressing all elements such as patient conditions, necessary equipment, and expected outcomes.
4. Indicate the CNS authority required to perform the procedure. Clarify whether the procedure is performed at your discretion or requires prior notification to a physician, and mention any relevant hospital privileges.
5. List any contraindications or limitations that may affect the CNS's ability to perform the procedure. This ensures transparency and adherence to best practices.
6. Outline your plan for an organized program of study. Include details on didactic teaching methods, instructor qualifications, and methodology—whether through simulation or hands-on experience.
7. If applicable, describe your plan for supervised practice, specifying the number of procedures required for initial training and ongoing competency validation, ensuring simulated experiences are limited appropriately.
8. Detail your plan for demonstrating competency, noting performance criteria for initial and periodic evaluations to maintain standards.
9. Obtain required signatures from the chief nursing officer, chief medical officer, and chief executive officer as confirmation of their approval. Have them include their names and license numbers along with the date.
10. Finally, review all entries for completeness and accuracy. Once satisfied, you can save your changes, download a copy for your records, print the form, or share it as necessary.

Complete your application online today to advance your nursing practice.