NEW GRADUATE PROVISIONS

Alabama Yes A nurse anesthetist "may request Provisional Approval for practice as a graduate nurse anesthetist by submitting: (a) Official evidence of authorization to test from the Council on Certification of Nurse Anesthetists for the initial certification examination. (b) The name and address of the employer who will ensure the supervision of the provisional nurse anesthetist by a certified registered nurse anesthetist or a licensed physician. The nurse anesthetist with provisional approval may use the designation Graduate Registered Nurse Anesthetist. Provisional approval to practice is limited to a maximum of one year and shall expire immediately upon: (a) Notification of passing the certification examination. (b) Notification of failing the certification examination." [Alabama Board of Nursing Admin. Code, sec. 610-X-9-.05] Alaska Yes The board may grant a nonrenewable permit to practice as a certified registered nurse anesthetist to an applicant who has been accepted to take the next scheduled certified registered nurse anesthetist examination; or (2) is awaiting results of the examination. [Professional Regulations, Board of Nursing, ch. 44, art. 5, sec. 12 AAC 44.530(a)] Arizona No reference Arkansas Yes The Nurse Practice Act of Arkansas does not prohibit "[t]he administration of anesthetics under the supervision, but not

Page 2 necessarily in the presence of, a licensed physician, dentist or other person lawfully entitled to order anesthesia by a graduate nurse anesthetist awaiting certification results while holding a temporary permit..." [Arkansas Code Ann., sec. 17-87-103(7)] A temporary permit may be issued to a graduate nurse anesthetist who meets certain educational criteria and who has been accepted by the certifying body to sit for the first national certification examination for which he or she is eligible. The temporary permit expires upon notification to the graduate nurse anesthetist of the results of the examination. [Arkansas Code Ann., sec. 17-87-307(c)(1) and (2)] California Yes The Nurse Anesthetists Act defines "graduate" as "a nurse anesthetist who is a graduate of an accredited program of nurse anesthesia awaiting initial certification results for not more than one year from the date of graduation." [Business and Professions Code, div. 2, ch. 6, art. 7, sec. 2826(e)] Colorado No The Colorado Board of Nursing does not issue temporary permits to APNs. Connecticut Yes The nursing statute does not prohibit a registered nurse who holds a master s degree in nursing or in a related field recognized for certification as... a nurse anesthetist by one of the certifying bodies identified in section 20-94a from practicing for a period not to exceed one hundred twenty days after the date of graduation, provided such graduate advanced practice registered nurse is working in a hospital or other organization under the supervision of a licensed physician or a licensed advanced practice registered nurse, such hospital or other organization has verified that the graduate advanced practice

registered nurse has applied to sit for the national certification examination and the graduate advanced practice registered nurse is not authorized to prescribe or dispense drugs... Upon notification... that the graduate advanced practice registered nurse has failed the certification examination, all privileges under this section shall automatically cease. [Conn. General Statutes, ch. 378, sec. 20-101] Delaware Yes "A temporary permit to practice, under supervision only, may be issued at the discretion of the Executive Director provided that: 8.10.2.1 The individual meets the requirements [regarding licensure, application, and fees] and; 8.10.2.2 The individual submits proof of graduation from a nationally accredited or Board approved Master's or certificate advanced practice nurse program, and; 8.10.2.3 The individual submits proof of admission into the approved certifying agency's examination... and is scheduled to take the first advanced certifying examination upon eligibility... or, 8.10.2.4 The individual meets 8.10.2.1 and 8.10.2.2 hereinabove and is awaiting review by the certifying agency for eligibility to sit for the certifying examination." [Board of Nursing Rules and Regulations, sec. 8.10.2] "A temporary permit will be withdrawn: Upon failure to pass the first certifying examination. The applicant may petition the Board of Nursing to extend a temporary permit under Page 3

District of Columbia Yes supervision until results of the next available certification exam are available by furnishing the following information: current employer reference, supervision available, job description, letter outlining any extenuating circumstances, any other information the Board of Nursing deems necessary." [Board of Nursing Rules and Regulations, sec. 8.10.5] "[T]he following persons shall be authorized to engage in the supervised practice of nurse-anesthesia without a District of Columbia certificate:... A graduate awaiting the results of the certification examination given by an approved certifying body..." [DCMR, Title 17, ch. 57, sec. 5711.1(2)] A graduate registered nurse-anesthetist may practice for no more than twelve (12) months from the date of graduation from an educational program accredited by the AANA." [DCMR, Title 17, ch.57, sec. 5711.11] Florida Yes "(1) Prior to certification by the appropriate professional or national nursing specialty board, applicants for certification as certified registered nurse anesthetists... may apply for provisional state certification. "(2) Each applicant for provisional state certification must be a graduate of an appropriate educational program pursuant to [board of nursing rules]. "(3) The provisional ARNP certification shall be valid for a period of 12 months. "(4) The provisional ARNP certification will expire if no specialty board certification is submitted within 12 months of the date Page 4

granting provisional ARNP certification." [Rules of the Florida Department of Health, Board of Nursing, Section 64B9-4.0025] Georgia No reference There is no provision explicitly addressing new graduate practice. As of August 2008, an applicant to practice as a certified registered nurse anesthetist must submit verification of current national certification/recertification from the Council of Certififcation/Recertification of Nurse Anesthetist. [Rules and Regulations of the Georgia Board of Nursing, sec. 410-12-.04(3)(b)4] Per the Georgia Association of Nurse Anesthetists, new graduates may not practice in Georgia prior to passing the certification exam as of August 2008. Hawaii No reference Idaho Yes "A temporary license to engage in advanced practice registered nursing may be issued to... [a]pplicants [a]waiting [i]nitial [c]ertification [e]xamination [r]esults. An otherwise qualified applicant who is eligible to take the first available certification examination following completion of an approved advanced practice registered nurse education program.... Temporary licensure to practice shall be deemed to expire upon failure of the certification examination. An applicant who fails the national certification exam shall not engage in advanced practice registered nursing until such time as all requirements are met. " [Administrative Rules of the Board of Nursing, IDAPA sec. 23.01.01, sec. 295.01] Illinois Yes To practice in license pending status, a graduate of an advanced practice registered nursing program may practice in the State of Illinois in the role of... certified registered nurse Page 5

anesthetist for not longer than 6 months after submitting information including, but not limited to, (1) an application for licensure as an advanced practice nurse, (2) proof of completion of a graduate advanced practice education program that allows the applicant to be eligible for national certification in a clinical advanced practice nursing specialty, and (3) proof of an application to take the national certification examination. Graduate nurse anesthetists practicing in license pending status must use the title license pending certified registered nurse anesthetist. [Illinois Nurse Practice Act, 225 ILCS 65/65-10] Indiana Page 6 No reference Iowa No reference Pursuant to a 1994 letter from the Iowa Board of Nursing, "temporary registration for ARNP [includes CRNAs] is no longer available..." Kansas Yes "The board may grant a temporary authorization to practice nurse anesthesia as a registered nurse anesthetist... for a period of not more than one year to graduates of a school of nurse anesthesia approved by the board pending results of the initial examination..." [Kansas Stat. Ann. sec. 65-1153(a)] Kentucky No APRNs, including CRNAs, may not practice in Kentucky prior to passing the certification examination. Louisiana Yes The educational and certification requirements "shall not apply to a graduate nurse anesthetist awaiting certification results, provided that the application for certification is made as soon as possible upon completion of the prescribed educational program in a school of anesthesia and provided further that this

is the initial attempt for passage of the certification examination." [La. Rev. Stat. 37 sec. 930(B)(3)] Maine Yes "Temporary approval to practice pending certification may be granted to a recent graduate of an approved nurse anesthesia program who meets [licensure and education requirements] and has applied to sit for the first available Council Certification Examination." "Such practice shall be under the supervision of an anesthesiologist or a certified registered nurse anesthetist." "Evidence shall be submitted that the applicant has applied for and is eligible to take the initial Council Certification Examination following graduation." "The applicant will identify her/himself as a graduate nurse anesthetist." "The applicant must pass the Council Certification Examination within 12 months of graduation. An applicant who fails the initial Council Certification Examination must practice as stated in 4(2)(B) [supervision requirement] and (D) [identify her/himself as a graduate nurse anesthetist.]" [Rules and Regulations of the Maine State Board of Nursing, Chapter 8, sec. 4(2)(A)-(E)] Maryland Yes "A registered nurse who has completed a program for preparation of nurse anesthetists and who has applied to take a national certifying examination acceptable to the Board may practice as a nurse anesthetist graduate before certification in the State, on approval of the Board, if the nurse... [p]ractices Page 7

Page 8 under the supervision of an anesthesiologist or CRNA, if the supervising CRNA has a collaborative agreement with an anesthesiologist, if the supervisor is on site and immediately available to the nurse anesthetist graduate." "A nurse anesthetist graduate who fails the certification examination shall immediately cease practice as a nurse anesthetist graduate. " [Regulations Governing the Practice of the Nurse Anesthetist, 10.27.06 sec..03] Massachusetts No Nurse anesthetists may not practice in Massachusetts prior to passing the certification examination, effective 2014. Michigan No reference Temporary certification in a nursing specialty field is not available in this state. [Board of Nursing Admin. Rules, R 338.10401a] Certification in a nurse specialty field is not required in Michigan, but is required to use the title nurse anesthetist. The Michigan Association of Nurse Anesthetists indicates that new graduates may practice in Michigan. The MANA relies on the statutory provision that states: "A licensee who holds a license other than a health profession subfield license may delegate to a licensed or unlicensed individual who is otherwise qualified by education, training, or experience the performance of selected acts, tasks, or functions where the acts, tasks, or functions fall within the scope of practice of the licensee's profession and will be performed under the licensee's supervision...." [Michigan Public Health Code, sec. 333.16215] No time limit is imposed by this section, although the MANA indicates that hospitals often limit the length of time new graduates may practice before passing the certification

exam. Minnesota No APRNs, including CRNAs, may not practice in Minnesota prior to passing the certification examination, effective January 1, 2015. Mississippi No Nurse anesthetists may not practice in Mississippi prior to passing the certification examination, effective 2017. Missouri Yes "A person who has graduated from an advanced nursing education program may be recognized by the Missouri State Board of Nursing as a Graduate Advanced Practice Registered Nurse for up to four (4) months from the date of graduation, pending a certification decision by an acceptable nationally recognized certifying body. [20 CSR 2200-4.100 (3)(B)] Graduate APRNs must [c]ease advanced practice nursing immediately upon notice that they have not successfully completed the certification process for any reason; and [n]otify the board within five (5) working days of the receipt of the results of their certification application. [20 CSR 2200-4.100 (5)] Montana Yes " (1) To qualify for a temporary permit, the applicant must hold a Montana RN license and provide the board with documentation of acceptance for the first certifying examination following completion of an APRN program. A copy of the examination authorization sent to the applicant by the national certifying body serves as documentation of acceptance. (2) If the graduate passes the certifying examination, the temporary permit remains valid until the board grants APRN licensure. (3) If the graduate does not pass the certifying examination, Page 9

privileges granted by the temporary practice permit are voided. The graduate shall notify the board of the examination results and return the temporary practice permit within five days of receipt of examination results. Failure to notify the board constitutes unprofessional conduct and may be a basis for proposed disciplinary action or license denial. (4) If the graduate fails to take the scheduled examination, privileges granted by the temporary practice permit are voided and the graduate must notify the board and return the temporary practice permit to the board office immediately. Failure to notify the board within five days constitutes unprofessional conduct and may be a basis for disciplinary action or license denial. (5) The graduate APRN working with a temporary APRN permit must have a consultant. The consultant must possess an unencumbered Montana license, except as provided by 37-1- 103, and be either an APRN or a physician whose practice encompasses the scope of the graduate APRN's practice. The consultant must be available to the graduate APRN at all times. [Montana Code Ann. sec. 24.159.1411] Nebraska Yes "The department may, with the prior approval of the board, grant a temporary license in the practice of anesthesia for up to one hundred twenty days upon application (1) to graduates of an accredited school of nurse anesthesia pending results of the first certifying examination following graduation and (2) to registered nurse anesthetists currently licensed in another state pending completion of the application for a Nebraska license. A temporary license issued pursuant to this section may be extended at the discretion of the board with the approval of the department." [Neb. Rev. Stat., 38-708] Page 10

Nevada Yes "A recent graduate of an accredited program for training as a nurse anesthetist may apply for temporary approval to practice as a nurse anesthetist. If temporary approval is granted, the applicant must take the first examination for certification available. During the period of temporary approval, the applicant must practice under the direct supervision of a currently certified registered nurse anesthetist... The temporary approval expires automatically... if the applicant fails the examination; or if the applicant does not take the first examination available." [Regulations of the Board of Nursing, sec. 632.535(1) and (3)(b)-(c)] New Hampshire Yes [A] new graduate of an advanced nursing practice educational program may seek a once-per-lifetime temporary licensure to practice in the advanced role following verification of authorization from the certifying agency to sit for the first national certifying examination in the applicant's specialty area. Each temporary APRN license shall expire at the earlier of [t]he passage of 120 days; or [t]he date on which the applicant receives either [a] permanent APRN license, after having made timely application; or [n]otice that the applicant failed the national certifying examination. As part of the application, the applicant shall provide a statement of agreement from an APRN holding a currently unencumbered APRN license issued by the NH Board of Nursing who agrees to oversee the applicant during the period of temporary licensure. Page 11

[New Hampshire Code of Administrative Rules, Nur 301.04(a)] New Jersey No Nurse anesthetists may not practice in New Jersey prior to passing the certification examination, effective 2017. New Mexico Yes Graduate registered nurse anesthetists may be issued a permit to practice "pending dissemination of the national qualifying examination results by the AANA Council on Certification of Nurse Anesthetists. GRNAs must function in an interdependent role as a member of a health care team and practice at the direction of and in collaboration with a physician, osteopathic physician, dentist or podiatrist." [NMAC, sec. 16.12.2.14(C)(1)-(2)] New York Yes The rules and regulations of the State of New York Department of Health known as "Medical Facilities Minimum Standards" (10 NYCRR Subchapter A) specify that a certified registered nurse anesthetist is a qualified practitioner of anesthesia services [Section 405.13(a)(1)(iv)]. The term "certified registered nurse anesthetist" is not defined in the state's "Medical Facilities Minimum Standards" rules and regulations, and the Department of Health utilizes the definition found in federal regulations [42 CFR Section 410.69(b)], which includes in the definition of "certified registered nurse anesthetist," a "graduate of a [nurse anesthesia educational program that meets the Standards of the Council on Accreditation of Nurse Anesthesia Programs who]... within 24 months after that graduation meets the requirements of paragraph (4)(i) of this definition [i.e., passes the certification examination]." [Letter dated April 25, 1996, from Maryellen Evans, Provider Group Coordinator, State of New York Department of Health] Page 12

Page 13 North Carolina No Nurse anesthetists may not practice in North Carolina prior to passing the certification examination, effective December 2010. North Dakota Yes "An applicant for advanced licensure who possesses a current registered nurse license, and has submitted a complete application, the required fee, and evidence of meeting all educational requirements, may be issued a ninety-day temporary advanced practice registered nurse permit for practice in an advanced practice registered nurse category if the applicant: 1. Is applying for licensure under section 54-05- 03.1-04; 2. Has applied as a first-time candidate to the next national nursing certification examination for the advanced practice registered nurse category; 3. Is awaiting certification results based upon initial application; or 4. Temporary permit will not include prescriptive authority. [North Dakota Admin. Code sec. 54-05-03.1-05] Ohio No reference There is no provision explicitly addressing new graduate practice. As of September 1997, an applicant to practice as a certified registered nurse anesthetist must submit documentation to the board of nursing indicating that the applicant has passed the certification examination of "the National Council on Certification of Nurse Anesthetists (sic) of the American Association of Nurse Anesthetists, the National Council on Recertification of Nurse Anesthetists (sic) of the American Association of Nurse Anesthetists, or another national certifying organization approved by the board..."

[Ohio Revised Code sec. 4723.41(A)(3)(b)] Per the Ohio Association of Nurse Anesthetists, new graduates may not practice in Ohio prior to passing the certification exam as of September 1997. Oklahoma No APRNs, including CRNAs, may not practice in Oklahoma prior to passing the certification examination, effective November 2011. Oregon Yes "A Graduate Registered Nurse Anesthetist (GRNA) may receive a limited license to practice within the CRNA scope of practice prior to attaining full certification if the applicant: (a) is a graduate of an accredited nurse anesthesia educational program; (b) meets all requirements for CRNA licensure other than full certification; (c) When providing anesthesia care, a GRNA shall have available for consultation a CRNA or anesthesiologist in the facility, until full certification from an approved certifying body is achieved. (d) The limited license shall expire 9 months following the date of graduation, or on issue of the CRNA license after full certification is attained, whichever is earlier. [Oregon State Board of Nursing Rules, OAR sec. 851-052-0020(3)] Pennsylvania Yes Until the announcement of the results of the first examination given for certification for which the noncertified registered nurse is eligible. Should a person fail to take or fail to pass the examination, the person shall immediately cease practicing as a nurse anesthetist. If the applicant, due to extenuating circumstances, cannot take the first scheduled examination following completion of the program, the applicant shall appeal to the Board for authority to continue practicing. [Rules and Page 14

Regulations for Registered Nurses, sec. 21.17(5)] Puerto Rico Yes The Board has the authority to "grant provisional licenses to female or male nurses from educational programs accredited by the Council on Higher Education and the Department of Education as pertinent." [Act to Regulate the Practice of Nursing, sec. 8(d)] Rhode Island No reference APRNs, including CRNAs, may not practice in Rhode Island prior to passing the certification examination, effective June 2013. South Carolina Yes Graduate Registered Nurse Anesthetist or GRNA means a new graduate of an advanced organized formal education program for nurse anesthetists accredited by the national accrediting organization who must achieve certification within one year of graduation or program completion." [Code of Laws of South Carolina, sec. 40-33-20(28)] South Dakota Yes "Upon application and payment of the required fee, the board may issue a temporary permit to practice as a certified registered nurse anesthetist to an applicant who has completed an approved program and is awaiting the results of the first examination that she is eligible to take after the temporary permit is issued. The temporary permit shall become invalid upon notification to the applicant of the results of the first examination." [South Dakota Codified Laws sec. 36-9-31.2. See also for a similar provision, South Dakota Board of Nursing Administrative Rules, 20:48:05:05] Tennessee No reference Page 15

Texas No APRNs, including CRNAs, may not practice in Texas prior to passing the certification examination, effective July 2011. Utah No reference The Utah Association of Nurse Anesthetists reports that nurse anesthetists may not practice in Utah prior to passing the certification examination. (In the past, the Utah Nurse Practice Act (NPA) and Board of Nursing Rules provided for new graduate practice. When the NPA was revised in 1998, the Utah Division of Occupational and Professional Licensing (which oversees the Board of Nursing) would not agree to the inclusion of a new graduate provision for nurse anesthetists in the nurse practice act. The Division's reason for this was that the nurse anesthetists' certification examination is now available via computer adaptive testing. An "intern license" is still available for APRNs in Utah, but not for nurse anesthetists.) Vermont No reference APRNs, including CRNAs, may not practice in Vermont prior to passing the certification examination, effective July 2011. Virginia Yes Provisional licensure may be granted to an applicant who satisfies all requirements for licensure with the exception of certification. The provisional licensure is only in effect "for either six months from date of issuance or until issuance of a permanent license or until he receives notice that he has failed the certifying examination, whichever occurs first." [Nurse Practitioner Regulations, 18 VAC 90-30-80(B)] Virgin Islands No reference Washington Yes "When authorized by the [nursing care quality assurance] Page 16

West Virginia No reference commission, the department [of health] shall issue an interim permit authorizing the applicant to practice... advanced registered nursing... from the time of verification of the completion of the school or training program until notification of the results of the examination. Upon the applicant passing the examination, and if all other requirements for licensing are met, the department shall issue the applicant a license to practice... advanced registered nursing.... If the applicant fails the examination, the interim permit expires upon notification to the applicant, and is not renewable." [RCW 18.79.180] A registered nurse licensed in the state of Washington who has completed advanced graduate education and is scheduled for a commission approved certification examination may be issued an interim permit for advanced nursing practice pending notification of the results of the first certification examination. The holder of an ARNP interim permit must use the title graduate advanced registered nurse practitioner (GARNP). [WAC 246-840-350(1)] Wisconsin No reference For further information concerning this issue, please see the Wisconsin Association of Nurse Anesthetists Web site at http://www.wiana.com/ (click Resources ). Wyoming Yes Graduate Temporary Permit (i) The Board may issue a graduate temporary permit for APRN, RN, LPN and CNA. However, a graduate temporary permit shall not include: (A) Prescriptive authority for GAPRNs. Page 17

(ii) A graduate temporary permit holder shall: (A) Be held to the established standards of nursing practice and CNA role; and (B) Practice only under appropriate direction and supervision as follows: (I) GAPRN supervised by APRN within the same specialty or physician (iii) If the applicant does not successfully pass the initial national examination, the graduate temporary permit shall expire and applicant cannot practice nursing in the State. [WY Dept. of Administration and Information/Board of Nursing rules, Ch. 2, sec. 6(b)] TOTALS: 29 states, the District of Columbia and Puerto Rico utilize explicit new graduate provisions. 21 states and the Virgin Islands do not include new graduate provisions. Page 18

SUMMARY TABLE: NEW GRADUATE PRACTICE STATUS May practice: Until results of first exam are received: Alabama (max. one year) Alaska Arkansas Connecticut (max. 120 days) Delaware* District of Columbia (max. one year) Idaho Kansas (max. one year) Louisiana Maryland Missouri (max. four months) *May be extended at the discretion of the state board of nursing Montana Nebraska (max. 120 days)* Nevada New Hampshire (max. 120 days) New Mexico North Dakota (max. 90 days) Pennsylvania* South Dakota Virginia (max. six months) Washington Wyoming May practice for up to: Six months Nine months One year 24 months Illinois Oregon California New York Florida Maine South Carolina Page 19