Physican Assistant: Verification of Pharmacological Course Work

Public Health: Physican Assistant: Verification of Pharmacological Course Work

DPH Data Management and Governance (PLIS)
TO BE COMPLETED BY APPLICANT
Applicant: Please complete the top portion of this form and forward to the educational institution, post-graduate program provider, NCCPA or American Academy of Physician Assistants for official verification of completion of pharmacology instruction for physician assistant practice.
Last Name:
First Name:
Middle Name:
Maiden Name:
Date of Birth:

MonthDayYear
Identification information if required by verifying entity (e.g., certification number):
TO BE COMPLETED BY EDUCATIONAL INSTITUTION ONLY
The applicant listed above is applying for physician assistant licensure in Connecticut. Please provide the following information regarding pharmacology instruction in the physician assistant educational program or in a post-graduate program for physician assistant practice.
Did this individual satisfactorily complete at least sixty (60) hours of didactic instruction in pharmacology for physician assistant practice?
If no, how many hours did this individual receive?
Where was such instruction completed?
Dates of candidate's attendance: from

MonthDayYear
To:

MonthDayYear
If in a post-graduate program, was the coursework Category I approved CME?
Who was the approval body (i.e. AAPA, AMA, AAFP, ACME)?
Comments:
Signature of Authorized Representative:
Date:

MonthDayYear
Title:
Institution:
Daytime Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Thank you for your assistance. Please return this form directly to:
Department of Public Health
Physician Assistant Licensure
410 Capitol Ave., Ms# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Should be Empty:

Public Health: Physican Assistant: Verification of Pharmacological Course Work

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY EDUCATIONAL INSTITUTION ONLY