“CNNAS Practical Nurse NURSING EDUCATION FORM The following information from your Application Form identifies you to the Nursing School/Educational Institution where you received your initial education as a nurse. Please ensure that the information is correct, and sign and date the form. Part A: PERSONAL INFORMATION NNAS ID number: 12493282 Application number: 99429 Firs/Given Name Middle Name asEamily Name Odimba Steve Loishaka Other names: Wungula + Your name used while attending this school diferont fom your eurent name): Lotshaka Odimba Wungula Mailing Address 10 Sunnylea Drive St Catharines,ON, Ontario L2M 528 Canada + Date ofbirth: 18/10/1965 + Phone number: (905) 996 -8358 E-mail address: wungulalo@gmail.com + Name of school of nursing/educational institution: International Training & Education Center for Health -University of ‘Washington Dept of Global Health + If your school closed or merged with another school, name of institution where transcripts and training records are archived: + Name of nursing or psychiatric nursing program: Clinical Mananagement of HIV + Your program start date: 07/01/2014 Your program completion/graduate date: 24/03/2014 Thereby give my consent to you to provide an original transcript of my nursing education directly to NNAS at the following address: NNAS P.O. Box 8658 Philadelphia, PA 19101-8658 USA, Your signature: Current date: 10/02/2016Part B: NURSING EDUCATION INFORMATION Please provide the following information (in English) concerning the nursing education of this nurse. Name of student while attending this schoo! Type of school/educational institution - Check one from the following: College ____Hospital_ University _ Secondary _ Vocational What are the minimum entrance requirements for admission to this program: Program start date: (The date this nurse started the program, in OD-MN-YYYY format) Program completion/graduate date: (The date this nurse graduated or formally completed the program, in DD-MM-YYYY format) Language of instruction - Theory: Clinical: What is the primary language of your educational institutio Name of credential/degree obtained - Options to choose’ Associate Degree Nurse _ Bachelor of Nursing Bachelor of Science in Nursing Enrolled Nurse Psychiatric Nurse_Praciical Nurse_ Other: Category of program: Check one: __nursing_ practical nursing __ psychiatric nursing Length of study for this program: How was the program primarily delivered - Check one response from the following (On site in class learning ‘online distance learning blended ___o other, (explain): This nursing program was officially recognized, approved or accredited by: Date program was approved or accredite (in DD-MM-YYYY format) ‘The quallly and completeness of the documents recelved by NAS from the school in response to the Nursing Education Form influences the degree of comparability yielded from the document-based assessment of your graduate’s credentials to Canadian hhursing education. Once an applicant's education assessment is complete and an advisory report has been issued, NNAS is 11 able to consider any additional curriculum related material unless the applicant reapolies and pays the associated fees. Please provide the following additional information and documents and include these with the completed form: Official anscript of this nurse's nursing education: This is the official document or record of the nurse's enrolment, progress and .chievement within your education institution. The transcript should identity courses taken (title and course number), credits and or yrades achieved, and credentials eared: ‘Nursing education program curriculum: a watten description of this nurse's program of study and its individual courses; And objectives, learning outcomes and hours of study. ‘Nursing education syllabus for each course: an outine and summary of the topics covered in each course, including course elena S029AS*GNEI Part C: EDUCATION DOMAIN BREAKDOWN In addition to attaching a copy of the offi of this nurse's nursing education, with a program curriculum and syllabus for each course, please provide specific hours of theoretical instruction, lab and hours of clinical practice for the subject areas listed below. Please do not combine subject areas. If they are combined in your curriculum, please estimate the number of hours in each subject area. ‘SUBJECT AREA Theory Hours ‘Simulation /Lab Hours Clinical Hours Nursing Gare of the Adult — Medical Nursing Care of the Adult — Surgical ‘Matornal Infant Nursing ‘Gynecology Pediatrie Nursing Gerontology / Ge Mental Health Nursing ‘Community Health / Public Health Nursing ‘Anatomy & Physiology Pathophysiology Microbiology Pharmacology & Medications Infusion Therapy Theory & Skills Nutrition Fundamentals of Nursing Health Assessment Across the Lifespan Leadership Ethical / Legal Practice ‘Applied Research Primary Health Care TOTALS Current address of this school of nursing / educational institution Name: Address 1: Address P.O. Box: CityrTown: ProvincelState/Terrtory Postel CodelZip Code: Country: aes nae TOUXANASGNEI Part D: IDENTIFICATION OF OFFICIAL Please provide the following information for the official authorized to provide the transct the rovide tran: Your complete printed name: Your official tite: Your signature: Current date: (Un Doerr ioral Your phone number: Alternate phone number: (ber inte format: 123-45. 7EBD, wn your cou eo85) {vere you can be reeched Knecezsay) Email address: Web site address: Please place the official seal or stamp of this organization here If the official providing the educational instruction information is a different official, please provide the name and signature of this official as well. Official authorized to provide educational information Your complete printed nam Your signature: Your phone number: (Wires frat 128-456-7890, wih you county cada) SSS Email Address: Your official title: Current dato: ‘on DONDE Yom) Alternate phone number: ‘where you cn be reached if necesse9) Please mail this completed form, with nursing education program documents and transcripts directly to: Malling address By Courier - Nas hinas P.O. Box 8658 3600 Market Street, Suite 400 Philadelphia, PA 19101-8658 USA Philadelphia, PA 19104-2651 USA depeston ruber 09428Practical Nurse NURSING EDUCATION FORM ‘The following information from your Application Form identifies you to the Nursing School/Educational Institution where you received your initial education as a nurse. Please ensure that the information is correct, and sign and date the form, Part A: PERSONAL INFORMATION NNAS ID number: 12493282 Application number: 99429 FirsU/Given Name Middle Name LastfEamily Name (Odimba Steve Lotshaka + Other names: Wungula ‘+ Your name used while attending this school, diferent from your current namo): Lotshaka Odimba Wungula Malling Address 40 Sunnylea Drive St Catharines, ON, Ontario L2M 528 Canada + Date ofbirth: 18/10/1965 + Phone number: (905) 935-8358 E-mail address: wungulalo@gmail.com + Name of schoo! of nursing/educational institution: INSTITUT SUPERIEUR DES TECHNIQUES MEDICALES DE LUBUMBASHI + Ifyour school closed or merged with another school, name of institution where transcripts and training records are archived: + Name of nursing or psychiatric nursing program: Diploma in general Nursing Medical Techniques Sciences + Your program start date: 04/09/1996 Your program completion/graduate date: 10/10/1999 I hereby give my consent to you to provide an original transcript of my nursing education directly to NNAS at the following address: nas Po aon ase Phindeipha, BA 10101-8658 oe L LSP 2 % Your signature: current date: 10/02/2016Part B: NURSING EDUCATION INFORMATION Please provide the following information (in English) concerning the nursing education of this nurse. + Name of student while attending this school: + Type of school/educational institution - Check one from the following Secondary ___ Vocational College __Hospital_ University + What are the minimum entrance requirements for admission to this program: + Program start date: (The date this nurse started the program, in DO-MMLYYYY format) + Program completion/graduate date: (The date this nurse graduated or formally completed the program, in DD-MM-YYYY format) + Language of instruction - Theory: Cinical: + What is the primary language of your educational institutio + Name of credential/degree obtained - Options to choose: Associate Degree Nurse__ Bachelor of Nursing Bachelor of Science in Nursing Enrolled Nurse Psychiatric Nurse___ Practical Nurse __ Other: + Category of program: Check one: nursing __ practical nursing _ psychiatric nursing + Length of study for this program: + How was the program primarily delivered - Chock one response from the following (On site in class learning conline distance learning blended ____or other, (explain): + This nursing program was officially recognized, approved or accredited by + Date program was approved or accredited: (in DD-MM-YYVY format) ‘The quail and completeness of ihe documents received by NNAS from the school in response to the Nursing Education Form influences the degree of comparability yielded from the document-based assessment of your graduate's credentials to Canadian nursing education. Once an applicant's education assessment is complete and an advisory report has been issued, NNAS is not able to consider any additional curriculum related material unless the applicant reapplies and pays the associated fees. Please provide the following additional information and documents and include these with the completed form: Official transcript of this nurse's nursing education: This isthe official document or record of the nurse's enrolment, progress and ‘achievement within your education institution. The transcript should identify courses taken (title and course number), credits and grades achioved, and credentials earned; + Nursing education program curriculum: a written description ofthis nurse's program of study and its individual courses; And + Nursing education syllabus for each course: an outline and summary ofthe topics covered in each course, including course objectives, leaming outcomes and hours of study.XCNNASYGNEI Part C: EDUCATION DOMAIN BREAKDOWN In addition to attaching a copy of the official transcript of this nurse's nursing education, with a program curriculum and syllabus for each course, please provide specific hours of theoretical instruction, lab and hours of clinical practice for the subject areas listed below. Please do not combine subject areas. If they are combined in your curriculum, please estimate the number of hours in each subject area. SUBJECT AREA ‘Theory Hours Clinical Hours Nursing Care of the Adult Medical Nursing Care of the Adult — Surgical Maternal / Infant Nursing ‘Gynecology Pediatric Nursing Gerontology / Geriatric Nur Mental Health Nursing ‘Community Health / Public Health Nursing ‘Anatomy & Physiology Pathophysiology Microbiology Pharmacology & Medications Infusion Therapy Theory & Skills Nutrition Fundamentals of Nursing Health Assessment Across the Lifespan Leadership Ethical / Legal Practice ‘Applied Research Primary Health Care TOTALS Curent address of ths schoo! of nursing / educational institution Name: Address 1: Address P.O. Box: Cityrtown: ProvincelState/Territory: Postal Code/Zip Code: Country:*CNNASXGNEI IDENTIFICATION OF OFFICIAI eis Please provide the following information for the official authorized to provide the transcript. Official authorized to provide tr Your complete printed name: Your official tite Your signature: Current date: Un OD-ANYYYY frmaty Your phone number: Alternate phone number: (suber inte format: 123-55 7EG0, wh your Coy Email address: (Were you canbe reaches necessan) Web site address: Please place the official seal or stamp of this organization here If the official providing the educational instruction information is a difforent official, please provide the name and signature of this official as well. Official authorized to provide educational information Your complete printed name: Your signature: Your official tit Current date: Your phone number: (Neribr foot 12486-7800, wih you Sauiy cod) Email Address: Weooanevryy math Alternate phone numb ‘ner you can be ached i recess) Please mail this completed form, with nursing education program documents and transcripts directly to: Mailing address By Courier NNAS NNAS P.O. Box 8658 3600 Market Street, Suite 400 Philadelphia, PA 19101-8658 Philadelphia, PA 19104-2651 usa USA Aypeaton marae 2029XNNASXGNEI