RECERTIFICATION 2014 Reaffirm your dedication to first assisting excellence. Recertify your CRNFA credential. Renew your CNOR credential.

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1 RECERTIFICATION 2014

2 Welcome to CRNFA Recertification The hallmark of an RN First Assistant s career Table of Contents Welcome CRNFA Eligibility Requirements... 1 Candidate Handbook... 1 CRNFA Recertification Methods... 2 Pricing... 2 Deadlines Retired Status... 3 Steps to Recertify... 3 Audit Policy... 3 Revocation of Credential Policy... 4 Contact Us... 4 Contact Hour Method Point Method Americans with Disabilities Act Exam Method Rescheduling and Cancelling Policy CRNFA Recertification Application Emeritus Application Practice Hour Documentation Form... 17

3 Welcome to CRNFA Recertification for 2014! CRNFA recertification is defined as the continued validation of the professional achievement of identified standards of practice by an individual registered nurse first assistant providing care for patients before, during, and after surgery. If certification provides some assurance to employers and the public of the achievements of those certified, it is only reasonable to expect that there be a basis for providing that assurance at more than just one time in an individual s career. The CRNFA recertification program provides that reassurance. If you hold both the CNOR and CRNFA credentials, these credentials were merged at the time you earned the CRNFA credential. This means that you only need to follow the CRNFA recertification process and pay the CRNFA recertification fee to renew both credentials. Objectives of CRNFA recertification include: Recognize the individual registered nurse first assistant (RNFA) who is proficient in practice. Strengthen conscious use of theory in assessing, planning, implementing, and evaluating patient care. Enhance professional growth through continued learning that results in broader knowledge and expanded skills. Purposes of CRNFA recertification include: Demonstrate concern for accountability to the general public for nursing practice. Enhance quality patient care. Identify RNFAs who have demonstrated professional achievement in providing care for patients during surgical intervention. Provide employing agencies with a means of identifying professional achievement of an individual RNFA. Identify professional nurses practicing in an expanded role. Eligibility Requirements All of the following requirements must be met at the time of application. Be currently licensed, without provision or condition, as a registered nurse in the country where currently practicing. Be currently certified as a CNOR or as an Advanced Practice Nurse. Have practiced, at some time, as an RNFA within the two years immediately prior to application. Be currently employed as an RNFA. Performed in the first assisting role for at least 500 to 1,000 practice hours over the last five years. The number of RNFA practice hours you have will determine the number of contact hours or points you need to recertify. Additional Eligibility Requirements for Advanced Practice Nurses (CNS, NP, CNM, CRNA) if recertifying by exam include: Certified as an advanced practice nurse by a nationally recognized certification program Proof of completion of 2,000 hours of first assisting Candidate Handbook The CRNFA Certification/Recertification Candidate Handbook contains important information and policies about certification and recertification and can be found at: CCI recommends all certificants review the Handbook as it contains important information about the recertification process. 1

4 CRNFA Recertification Methods CCI offers three methods for CRNFA recertifi cation so you can choose the method that works best for you. Any method you successfully complete will fulfi ll your requirements for recertifying your CNOR and CRNFA merged credentials. 1. Contact Hours (pages 4-5) 2. Points (pages 6 9) 3. Exam (page 10) 2014 Pricing Early Discount Recertification Fees January 1 July 1, 2014 Standard Recertification Fees July 2 December 31, 2014 Method Regular AORN Member Regular AORN Member Contact Hours $550 $425 $625 $500 Points $550 $425 $625 $500 Exam $550 $425 $625 $500 Retired (one time fee) $95 $95 $95 $95 Deadlines All fees and policies are subject to change. Application Deadline Online applications open on January 1, The deadline to receive the early recertifi cation discount is July 1, The deadline for standard recertifi cation rate is December 31, Applications received after December 31, 2014 will be declared ineligible. Contact Hour and Points Deadline If you are using the contact hour or point method to recertify, please note contact hours, points and practice hours must be earned between January 1, 2009 and December 31, CRNFA Credential Contact Hours and Points Valid From Must Be Earned Between Application Deadline Jan. 1, Dec. 31, 2013 December 31, Jan. 1, Dec. 31, 2014 December 31, Jan. 1, Dec. 31, 2015 December 31, Jan. 1, Dec. 31, 2016 December 31, 2017 CRNFA status will lapse on December 31, 2014 if: An acceptable number of contact hours are not submitted (for contact hour recertifi ers) The appropriate amount of points are not submitted (for point method recertifi ers) The exam is not passed (for exam recertifi ers) Recertifi cation fee is not paid. Lapsed CRNFA status can be reinstated by: Meeting current eligibility requirements and, Successful completion of the examination. 2

5 Retired Status CRNFA Emeritus [CRNFA (E)] credential recognizes CRNFAs who have retired from professional nursing but wish to maintain their credential in an emeritus capacity. You may choose to retire only your CRNFA credential or both your CNOR and CRNFA credential. Either way, the one-time fee is $95. If you choose to retire only your CRNFA credential, you will hold the CRNFA (E) credential. To maintain your CNOR credential, you must complete the CNOR recertification process. If you retire both credentials you will hold the CNOR (E) and CRNFA (E) credentials. Steps to Recertify If you are an AORN member, you will need to have your AORN login and password to receive your discount. All applicants will need to electronically sign a Statement of Understanding and complete the payment process. You have the option to pay online with a credit card, or print out an invoice and send it in with your check payment. 1. Logon to your account at 2. Update your account information. If you are an AORN member, you will need to have your AORN login and password to receive your member discount. 3. Electronically sign a Statement of Understanding. 4. From the Recertification options on the left navigation select one of the following: a. Recertify CRNFA by Contact Hours 1. Performed in the first assistant role for at least 500 hours 2. Complete online contact hour log and online application 3. See additional details on pages 4 5. b. Recertify by Points 1. Performed in the first assisting role for at least 500 hours 2. Complete paper application (pages in this booklet) 3. Complete Points Activity Form (pages 6 9 in this booklet) c. Recertify by Exam 1. Performed in the first assistant role for at least 1,000 hours with at least 500 hours must be related to care given during the intraoperative period. 2. Complete online application by September 30, 2014 and successfully pass the exam by December 31, See additional details on page 10. d. Apply for Emeritus (retired) Status Complete online application or paper application (pages 15-16) before December 31, Complete the payment process You have the option to pay online with a credit card, or print out an invoice and send it in with your check payment. Audit Policy CCI randomly audits 10% of applications it receives for recertification. Applicants selected for audit are notified by and are required to submit the following: Copies of all certificates for contact hours. A copy of the appropriate transcript including the specific course(s) being used, if academic credits are submitted for re-certification by the contact hour method. Note: Unofficial transcripts are acceptable. All required documentation for recertification by the Points method. A log of your hours attained in the RNFA role for the last 5 years, or a written letter with signature(s) from the surgeons with whom you work verifying hours served as an RNFA over the past 5 years. 3

6 Revocation of CRNFA Certification Policy Grounds for revocation or other disciplinary action by CCI include, but are not limited to: 1. Falsifi ed information on the certifi cation or recertifi cation application. 2. Having certifi cant s current RN license revoked/suspended by a state board of nursing. 3. Certifi cant being placed on probation by a state board of nursing. 4. Committing a breach of the confidentiality agreement (i.e., via public or printed communication, Internet, etc.) signed at the time the examination was taken. 5. Nonpayment of any debts owed to CCI. 6. Violation of misconduct policies in the CRNFA Certifi cation/recertifi cation Candidate Handbook. There will be no refund if, for any reason, the CRNFA status is revoked. Certifi ed nurses will be notifi ed by letter of CCI s decision to revoke the CRNFA status. CCI also reserves the right to contact the employer, the state board of nursing, insurance company or other public health agency to inform them of any certifi cant for whom the credential has been revoked. Contact Us info@cc-institute.org Mail: CCI 2170 S. Parker Rd, Suite 295 Denver, CO Phone: (8:00 am to 4:00 pm MST Monday - Friday) Fax: CRNFA Recertification by Contact Hours Contact Hour Requirements First Requirement Each nurse must have a minimum of 500 clinical practice hours. The amount of clinical practice hours you earn determines the number of contact hours you must also accumulate. If you have: Between 500 and 1,000 clinical practice hours If you have: 1,000 clinical practice hours or more Four Additional Contact Hour Requirements 1. At least half of your contact hours must be RNFA specific topics: NUMBER OF CONTINUING EDUCATION CHs NEEDED è è Then You Need: 300 Contact Hours Then You Need: 200 Contact Hours If: 200 contact hours are required è Then: At least 100 must be RNFA specific topics è And: At least 50 must be in general perioperative related topics If: 300 contact hours are required è Then: At least 150 must be RNFA specific topics è And: At least 75 must be in general perioperative related topics 2. Contact hours must be accrued within the five year period beginning January 1, 2009 and ending December 31, Contact hours must be earned through an accepted provider (see list on next page). 4. Contact hours must be entered into your CCI online account. 4

7 CRNFA Recertification by Contact Hours Continued... Accepted Providers American Academy of Family Physicians (AAFP) American Academy of Nurse Practitioners (AANP) American Academy of Physicians Assistants (AAPA) American Association of Critical-Care Nurses (AACN) American Association of Neuroscience Nurses (AANN) American Association of Nurse Anesthetists (AANA) American College of Nurse Midwives (ACNM) American Nurses Credentialing Center (ANCC) An agency, organization, or educational institution accredited by ANCC Association of Women s Health, Obstetric, and Neonatal Nurses (AWHONN), formerly NAACOG Any state nurses association National Association of Clinical Nurse Specialists (NACNS) National Association of Nurse Practitioners in Women s Health (NPWH) National Association of Pediatric Nurse Associates and Practitio- ners (NAPNAP) State boards of nursing in: CA, FL, KS, KY, IA, NV,AL, OH, LA,WV RNFA-Specific Subject Matter Scope of practice Nursing process for RNFAs Asepsis, infection control, and epidemiol- ogy Surgical anatomy and physiology Intraoperative RNFA nursing behaviors Assisting considerations and procedure management (including specific surgical procedures and assisting techniques) Surgical hazard recognition and intervention (including lab values and EKG interpretation) Communication skills (including profes- sional writing and presentations) Professional development (ethics, mentoring and precepting, leadership skills, self-care issues, critical thinking skills, practice management, entrepreneurship, marketing, reimbursement issues, negotia- tion and contract skills) Trauma and physical assessment Pre- and postoperative patient care (rounding, patient education, etc.) Pharmacology Patient safety issues Pathophysiology Discharge planning Medical record dictation Legal, policy, and practice issues Home health care relating to RNFA practice Technology changes/advances and their effect on the RNFA role Health care reform CRNFA review Managed care (critical pathways, utiliza- tion review, outcomes) Invasive and noninvasive diagnostic pro- cedures Surgical complications Wound management Materials management/product review Bioterrorism Verification & Audit All information on applications is subject to verification by CCI. Authorized personnel will check applications for accuracy and integrity. Information may be verified by telephone and/or letter. All information gained through verification procedures will be confidential, except in instances where the law demands disclosure of facts. Should any information on an application or contact hour record form be false, the applicant will be notified and declared ineligible to continue the application process.applicants selected for the random audit will be notified by after the application process has been completed. If selected, the applicant will be required to submit copies of all certificates of attendance, education certificates, and/or copies of any academic credits that are being used for recertification. Audit information on practice hours includes the date, surgeon s initials, surgical procedure, and time spent in pre, intra, or postoperative period. If this information is not documented, information submitted must include a letter(s) from surgeons with whom you have assisted. Information in the letter must include the approximate number of hours worked per 5 year recertification cycle. 5

8 CRNFA Recertification by Points CRNFA Recertifi cation by Points recognizes that learning and competency maintenance are accomplished in a variety of ways and that learning is achieved through successful participation in a variety of professional activities. The number of Points required for recertifi cation depends on the clinical hours you have completed over the last five years. Points for CRNFA recertifi cation may be acquired through the participation in 8 categories or activities. Points Requirement The number of points you are required to earn to recertify depends on the number of clinical practice hours you have documented over the last five years. To recertify in 2014, the clinical practice hours must be accumulated between January 1, 2009 and December 31, a. If you have more than 1,000 clinical practice hours (of which at least 700 hours must be intraoperative care), you must earn 400 points. b. If you have between 500 and 1,000 clinical practice hours (of which at least 350 hours must be intraoperative care), you must earn 500 points Application Process To recertify by Points, you must submit the following: CRNFA recertification application (paper) (see p.12-14) + Points Activity Form (p.6-9) + Appropriate fee If you are audited you will need to submit the acceptable documentation listed with each category. 1. Continuing Education - maximum of 100 points Acceptable documentation (only necessary if you are audited) Copy of certificate(s) of attendance from an accepted provider. Example: 1 contact hour è 2 points 2014 Points Activity Form Program Title Date of Program Name of Provider Program Accredited By Contact Hours Points You may make copies of this page. Total: Maximum of 100 points or 50 contact hours 6

9 2014 Points Activity Form 2. Academic Study Toward Health care Related Degree Completion - Unlimited Points All courses taken toward a health care degree (BSN, MSN, DNP, etc.) or a degree (including MBA) where the knowledge attained is used to advance your career in perioperative nursing. Copy of unofficial transcript. Conversion rate for academic credits: 1 semester hour/credit è 15 points 1 quarter hour è 10 points Name of College or University Title of Course Semester or Quarter Hours Year Points Unlimited points can be earned in this category. Total: 3. Publishing - Maximum of 150 Points Acceptable documentation (only necessary if you are audited) A copy of the title page, table of contents, or abstract indicating that you are the author, co-author, or contributor. Maximum Number Maximum Points Author of chapter in perioperative book è 50 points/chapter Editor of perioperative book è 50 points 1 50 Author of professional journal article è 25 points/article 3 75 Guest editor of journal issue è 10 points/issue 3 30 Book reviewer è 5 points/review 3 15 Title of Publication Type of Publication Contributing Role Year Published Points Maximum of 150 points can be acquired in this category. 7 Total:

10 2014 Points Activity Form 4. Service as a Board or Committee Member - Maximum of 150 points. Acceptable documentation (only necessary if you are audited) Board summary, minutes, or committee report (minimum of 4 meetings per year required). International, National or State Board, or Chapter Committee Member è 30 points per year Health care facility committee member è 15 points per year Specialty Assembly Governing Council Member è 20 points per year Title of Board or Committee Role on Board or Committee Level of committee Dates of service Points Maximum of 60 points can be acquired in this category. Total: 5. Presentations - Maximum of 150 points. Acceptable documentation (only necessary if you are audited) Program brochure, activity documentation form (ADF), or completed course evaluation. Each document must include title, presentation, date, and objective(s) of presentation. All presentations and/or seminars must be on different topics. Maximum Number Maximum Points AORN Expo presentation/seminar è 30 points/presentation points Each 60 minutes of an in-service presentation è 10 points/presentation 5 50 points Title of presentation Length of presentation Date of presentation Points Maximum of 150 points can be acquired in this category. Total: 8

11 2014 Points Activity Form 6. Teaching - a perioperative related course in an academic setting (i.e., college or university). Maximum of 60 points. Acceptable documentation (only necessary if you are audited) Syllabus or course description. Each class è 30 points College or University Title of Course Semester & Year Taught Points Maximum of 60 points can be acquired in this category. Total: 7. Precepting/Mentoring in the RNFA role (ie, mentoring and/or orienting a new RNFA employee) - Maximum of 75 points. Acceptable documentation Complete information below. Each precepted employee è 25 points Learner s Initials Inclusive Dates of Preceptor Experience Date of Completion of Orientation Points Maximum of 3 different employees allowed = 75 points Total: Grand Total: Points must be earned between January 1, 2009 and December 31, 2013 to recertify by Points Method in Cross Training in a New Perioperative Practice Area Maximum of 90 points. Examples of new perioperative practice areas include GI lab, cath lab, wound care, IV therapy, grand rounds. Orientation to a new facility is not eligible. Complete information below. 1 area è 30 points Area Date Points Maximum of 3 different employees allowed = 75 points Total: 9

12 CRNFA Recertification by Examination Eligibility Requirement CRNFAs who are recertifying by exam are required to have 1,000 clinical practice hours (at least 500 hours must be related to care given during the intraoperative period). The CRNFA Exam CCI has contracted with a professional testing service, Prometric, to administer and score the CRNFA exam at testing centers throughout the United States. CRNFAs may register to take the exam between January 1, 2014 and July 1, 2014 to earn the early discount. If you register for the exam between July 2, 2014 and September 30, 2014, the standard fee will apply. If you do not successfully pass the exam by December 31, 2014, your CRNFA credential will lapse. If you hold a merged CNOR/CRNFA credential and you fail the exam both of your credentials will lapse. The CRNFA exam consists of 150 multiple-choice questions.you have two hours and 45 minutes to complete the exam. Scores are based on the number of correct answers. A passing score was established via a systematic procedure (Cut-Score Study) that employed the judgment of a represen tative group of CRNFAs from across the country with the assistance of staff from Prometric.This group recommended a standard of what a minimally competent CRNFA needs to know about the tested content to obtain a passing score.this method maintains the passing score at a scaled score of 620. Americans with Disabilities Act Whenever possible, the Competency & Credentialing Institute is committed to providing a reasonable accommodation in its examination process to otherwise qualified individuals with physical or mental disabilities in accordance with the Americans with Disabilities Act (ADA). Accommodations will be provided to qualified candidates with disabilities to the extent that such accommodations do not fundamentally alter the examination or cause an undue burden to the agency. Candidates with disabilities must notify CCI in writing no later than 60 days prior to the examination testing window stating the specific type of accommodation needed and providing appropriate documentation of the disability. Please refer to the CRNFA Candidate Handbook on the CCI website. 10

13 Policies and Procedures for Rescheduling and Cancelling Earlier of: days prior to end of testing window days prior to scheduled test date Change Appointment within the Testing Window Two Steps 1. Contact Prometric and cancel your appointment. 2. Reschedule your appointment with Prometric. No fee will be charged. no fee Transfer to Next Testing Window Two Steps 1. Contact Prometric and cancel your appointment. No fee will be charged. Withdrawal from Exam Two Steps 1. Contact Prometric and cancel your appointment. No fee will be charged. Between 29 and 5 days prior to end of testing window or test date Two Steps 1. Contact Prometric and cancel your appointment. 2. Reschedule your appointment with Prometric. A fee of $50 will be charged. This fee will be charged each time you reschedule your appointment. 2. Transfer from your testing window to the next testing window by logging into your CCI account and completing the transfer request. A fee of $75 will be charged. $75 Two Steps 1. Contact Prometric and cancel your appointment. A fee of $50 will be charged. $50 2. Withdraw your application by logging into your CCI account and completing the withdrawal application. $75 of your exam fee is non-refundable. $50 Two Steps 1. Contact Prometric and cancel your appointment. A fee of $50 will be charged. $50 $75 5 days prior to end of testing window or test date You are unable to reschedule or cancel. You must appear and sit for the exam or all fees will be forfeited. X You are unable to transfer. You must appear at your scheduled time and sit for the exam or all fees will be forfeited. You are unable to withdraw. You must appear at your scheduled time and sit for the exam or all fees will be forfeited. X X Test Day Arrive Late for Testing Appointment / No Show Fees will be forfeited if you: Are late for your test appointment. Miss your scheduled appointment date. Contact Prometric at or Never make an appointment. 11

14 2014 CRNFA Recertification Application Applications must be postmarked on or before July 1, 2014 to receive the early discount. This application will recertify your merged CNOR/CRNFA credential. Mail to: CCI, 2170 South Parker Road, Suite 295, Denver, CO Or, fax your application to If you fax your application, please call on the same day to confirm receipt. CRNFA Recertification Fees Check One CRNFA Recertification Method Early Discount Regular Early Discount AORN Member Standard Regular Standard AORN Member Contact Hours $550 $425 $625 $500 Points $550 $425 $625 $500 Exam $550 $425 $625 $500 To receive the AORN member price, you must be a member of AORN member on the day you submit this application. NOTE: If you are recertifying by Points please include the Points Activity Form. If you are recertifying by contact hours please include your contact hour log. Deadlines The deadline to receive the early discount pricing is July 1, The final application deadline is December 31, 2014 unless you are recertifying by exam. The deadline to apply to recertify by exam is September 30th. If you do not test by December 31, 2014 and pass the exam, your CRNFA credential will lapse. Application Information (All fields required) Name: Last, First, Middle Last 4 digits of Social Security Number: Birth Year: AORN Username: AORN Password: AORN#: Home Address: City State Zip Work Phone: Home Phone: State in which you are currently licensed as an RN: 12

15 Check your current position: Administrator/VP Director/Manager Researcher Charge Nurse Educator Staff Nurse Clinical Nurse Specialist Faculty Traveling Nurse Supervisor/Coordinator Nurse Practitioner Health Care Industry Representative Consultant RN First Assistant Private Scrub Nurse Check your practice areas: Academia/Teaching Podiatry Interventional Radiology Cardiac Catheterization/Procedure Lab Pediatrics Obstetrics Bariatric Robotics Laser Endoscopy Plastics/Reconstructive Oncology Cardiothoracic Transplantation Neurosurgery General Surgery Have you obtained a degree since your last certification? No Yes Ophthalmology Trauma Gynecology Orthopedics Urology Infection Control Otolaryngology (ENT) Vascular Informatics Please list degree(s) obtained Check your type of facility: Academic Institution Agency/Travel Nurse Ambulatory Free standing Ambulatory Hospital based Ambulatory Office based Clinic Hospital Military/Government Facility Physician/Surgeon Office Self-Employed Check your Magnet Status: Have Magnet Designation Do not have Magnet Designation Working towards Magnet Designation List facilities where you have practiced as a first assistant over the past two years, beginning with your present facility. Do not send resume. Use an additional sheet of paper if more space is needed. From Mo/ day/yr To Mo/day/yr Employer and Address Write out employer s name Position, title, specialty Ex. Staff nurse, CRNFA, OR Supervisor s Name Number of Hours per Week 13

16 Employment Verification Please provide contact information for your supervisor where you currently practice. This will be used to verify employment in perioperative nursing. Current Supervisor s Name Current Supervisor s Current Supervisor s Phone Please provide contact information for a surgeon you currently work with. This will be used to verify your role and performance as a first assistant at surgery. Surgeon Name Facility Surgeon Phone Surgeon s Practice Requirement: State the total number of hours you have practiced as a CRNFA between January 1, 2009 and December 31, Total hours (not years): I attest by signature that I have practiced these hours as a CRNFA, and I am currently employed in perioperative nursing. Applicant s Signature: Date: Statement of Understanding. I hereby apply for recertification offered by the Competency & Credentialing Institute. I understand that recertification depends upon the successful completion of the specified requirements. I further understand that the information acquired in the recertification process may be used for statistical purposes and for evaluation of the recertification program. I further understand that the information from my recertification records shall be held in confidence and shall not be used for any other purposes without my permission. To the best of my knowledge, the information contained in this application is true, complete, correct and made in good faith. I understand that information supplied is subject to audit, and that failure to respond to a request for further information will result in termination of the application process. I understand that CCI reserves the right to verify any or all information on this application. I affirm and attest that I have read and agree to abide by the Statement of Understanding. Signature: Print Name Date Payment Information Payment Method: Check or Money Order Visa Mastercard Discover Card American Express (Make payable to CCI ) / Credit Card Number Expiration Month/Year Security Code Billing Zipcode: Required for credit card payment Cardholder Signature Billing State: Amount to be charged to credit card: $ Date: / / (from page 12) 14

17 2014 CNOR (E) / CRNFA (E) Application Retired Status. One Time Application Fee of $95 Check one I am applying for CRNFA retired status only. I will keep my CNOR active. You must complete the CNOR recertification process by the deadline. I am applying for both CNOR and CNRA retired status. What is CNOR (E) and CRNFA (E)? In recognition of retired RN First Assistants and their service to our profession, as well as their achievement and maintenance of the CRNFA credential, CRNFA(E) Emeritus Status was instituted by the Competency & Credentialing Institute in This credential recognizes the CRNFA who has retired from their professional nursing career but wishes to maintain their CNOR and/or CRNFA credentials in an emeritus capacity. Application Information To apply for CNOR(E) and/or CRNFA(E) status, complete this application and submit it along with a one-time fee of $95 to CCI at 2170 South Parker Road, Suite 295, Denver, CO or fax to (303) If you fax your application, please call (888) on the same day to confirm receipt. All Fields Required 1. Name: Last, First, Middle 2. Last 4 digits of Social Security Number: 3. Home Address: City State Zip 4. Home Phone: 5. Date of Retirement: 6. Original Certification Date: 7. List facilities where you have practiced perioperative nursing for the past two years, beginning with your last facility. Do not send resume, use an additional sheet of paper if more space is needed. From Mo/ day/yr To Mo/day/yr Employer and Address Write out employer s name Position, title, specialty Ex. Staff nurse, CRNFA, OR Supervisor s Name Number of Hours per Week 15

18 Fee CNOR(E) and/or CRNFA(E) (retired status) One-time application fee $95 Statement of Understanding I, have retired from perioperative nursing with no plans to return, and I understand that I will have to successfully complete the CRNFA Exam to regain the CRNFA credential. Once your application, and $95 application fee has been received and approved, your CNOR(E) and/or CRNFA(E) certificate will be mailed to you. Please allow 4-6 weeks for delivery. Applicant s Name: Signature: Payment Information Payment Method Check or Money Order Visa Mastercard Discover Card American Express (Make payable to CCI ) / Credit Card Number Exp Date Security Code Amount to be charged on my credit card: $ Billing Zipcode (required for credit card payment) Cardholder Signature: Billing State: Date: / / 16

19 CRNFA Practice Hour Documentation Form Name (Please Print): If you are selected for audit, you will need to provide documentation of your practice hours. Audit information includes the information below. If this information is not documented, information submitted must include a letter(s) from surgeons with whom you have assisted. Information in the letter must include dates, types of cases, and the approximate number of hours worked per month. You may make copies of this form if needed. Date Surgeon s Name or Initials Surgical Procedure Pre-Op Time Intra-Op Time Post-Op Time Page Totals: Grand Totals: 17

20 Notes 18

21 Notes 19

22 2170 South Parker Road, Suite 295 Denver, CO or Reaffirm your dedication to first assisting excellence. Recertify your CRNFA credential. CRNFA recertification recognizes your ongoing commitment to specialized knowledge and skills in fi rst assisting. CRNFA recertification is your pathway to further your knowledge, to continue validating your practice and to help advance the field of perioperative nursing. Renew your CNOR credential.