Verification of Bedside Hours for CCRN-E Renewal

Certification Organization for the American Association of Critical-Care Nurses
Verification of Bedside Hours for CCRN-E Renewal
3-Year CCRN-E Renewal Audit Period: ____________ – ____________
CERTIFICANT:
This form must be completed by your supervisor or a professional colleague (RN or physician), confirming that you
fulfilled the requirement of monitoring and caring for acutely and/or critically ill adult patients in a tele-ICU or in a
combination of tele-ICU and direct bedside care for a minimum of 432 hours during the last 3-year certification
period, with 144 of those hours accrued in the 12-month period prior to your scheduled renewal date. This form
must contain contact information for your verifier.
VERIFIER:
Please complete and sign the below verification and return this form to the certificant to include in their audit
packet.
I, ___________________________________, verify that ___________________________________ has fulfilled
(printed name of verifier)
(printed name of certificant)
the requirement of monitoring and caring for acutely and/or critically ill adult patients in a tele-ICU or in a
combination of tele-ICU and direct bedside care for a minimum of 432 hours during the last 3-year certification
period, with 144 of those hours accrued in the 12-month period prior to their scheduled renewal date. To the best
of my knowledge, the information I am providing is accurate and submitted in good faith. I understand that I may be
contacted by AACN to validate the information provided.
_________________________________________
Verifier’s Title
_________________________________________
Verifier’s Signature
Date
_________________________________________
Hospital Name
_________________________________________
Hospital City & State
_________________________________________
Verifier’s Business Email
_________________________________________
Verifier’s Business Phone
All fields must be completed.
101 Columbia  Aliso Viejo, CA 92656  (800) 899-2226  www.certcorp.org
10-2014