Faculty Qualification Report (FQR) jQuery UI Datepicker – Default functionality This form must be submitted to KSBN by Program Administrator within 30 days of appointment. Initial Update Name of Appointee as appears on nursing license Nursing License # Nursing License State Nursing License Expiration Date (mm/dd/yyyy) Employment Date Employment Status Please Select Employment StatusFull TimePart TimeAdjunctOther Name of Program Address of Program Type of Program Please Select Type of ProgramADNBSNDNPMSNPN APPOINTMENT TEACHING & CLINICAL RESPONSIBILITIES Please include the title of the course, the amount of credit hours each course is and whether the course is lecture or clinical instruction. INITIAL PRE-LICENSURE PREPARATION IN NURSING Nursing Program Attended City/State of Nursing Program Graduation Date (month & year) Diploma ADN BSN MSN Entry ADDITIONAL EDUCATION OBTAINED College/University Degree or Certification / Major Presently Enrolled Please select Yes/No YesNo Credits Earned Degree/Certification Awarded Please select Yes/No YesNo Year ADDITIONAL EDUCATION OBTAINED College/University Degree or Certification / Major Presently Enrolled Please select Yes/No YesNo Credits Earned Degree/Certification Awarded Please select Yes/No YesNo Year ADDITIONAL EDUCATION OBTAINED College/University Degree or Certification / Major Presently Enrolled Please select Yes/No YesNo Credits Earned Degree/Certification Awarded Please select Yes/No YesNo Year TRANSCRIPT: Required for original RN licensure degree and any additional nursing education received. Can be uploaded on the next Page. DEGREE PLAN: Required when appointee does not have the required nursing degree per K.A.R. regulation for the program level they are teaching, but is currently enrolled in a program. Link to form in confirmation of this submission. HIRE EXCEPTION: Required when appointee does not have the required nursing degree and is not currently on a degree plan. Link to form in confirmation of this submission. PROGRAM ADMINISTRATOR INFORMATION Name of Program Administrator Email Address for correspondence of this form. Attestation I realize that this application is a legal document and by pressing the Submit button I am declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge. If all the above information is correct please press the Submit button . Otherwise please go back and correct any information that is necessary. SUBMIT WILL CONTINUE YOU ON TO THE FILE UPLOAD PAGE
