Registered Nurse – Nursing Education Form

The following information identifies the applicant to the Nursing School/Educational Institution where nursing education was
received. Ensure that the information is correct, then sign and date each form. Provide each populated form to the Nursing
School/Educational Institution to be completed and mailed directly to NNAS.

PART A: PERSONAL INFORMATION

NNAS ID Number: 9107920 Application Number: 347258
First/Given Name: Maria Lourna Date of Birth: December 27, 1991
Middle Name: Templa Phone Number: 6475101956
Last/Family Name: Igsoc Email Address: najmahigsoc17@gmail.com
Other Names:

Name used when attended this school: Maria Lourna Igsoc

Mailing Address:
Address 1: 52 Monk Crescent
Address 2:
City/Town: Ajax
Province/State/Territory: Ontario
Postal Code/Zip Code: L1Z1H4
Country: Canada

Name of school of nursing/educational institution: CAMIGUIN POLYTECHNIC STATE COLLEGE

• Did this school close or merge with another school? No

• If yes, name of institution where transcripts and
training records are archived:

Name of nursing education program: Bachelor of Science in Nursing

Attendance Start Date: June 10, 2012

Attendance End Date: March 23, 2014

I, Maria Lourna Templa Igsoc hereby give my consent to CAMIGUIN POLYTECHNIC STATE COLLEGE to provide
the information and documents related to my nursing education requested in this form, and to send this completed form and
documents directly to NNAS at the following address:

NNAS
P.O. Box 8658
Philadelphia, PA 19101-8658
USA

Applicant's Signature: Date Signed: 15/02/2023

(dd/mm/yyyy)

If you have any questions, please contact NNAS via +1 (215) 349-9370 or use the Contact Us option in your applicant portal.

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Maria Lourna Templa Igsoc ■ CAMIGUIN POLYTECHNIC STATE COLLEGE
Order #: 347258 ■ February 15, 2023 ■ Rev: Aug 2017 ■ Page 1 of 5
 PART B: NURSING EDUCATION INFORMATION
To be completed by the official authority. Please provide the following information (in English) concerning the nursing
education of this applicant. Please spell out all names fully (no initials or abbreviations).

Do not leave any field blank; mark questions that are not applicable as N/A.

Name of student as it appears on official transcript:

Type of school/educational institution:

☐ Secondary ☐ Vocational ☐ College

☐ Hospital ☐ University

What are the minimum entrance requirements for admission to this nursing program?

Date this applicant started the program:

(dd/mm/yyyy)

Did this applicant complete the program? ☐ Yes ☐ No

If Yes, date this applicant graduated or formally completed the program:
(dd/mm/yyyy)
If No, last date of attendance:
(dd/mm/yyyy)
Language of Theory instruction:
Language of Clinical instruction:

What is the primary language of the educational institution?

Name of credential/degree obtained:

☐ Associate Degree Nurse ☐ Bachelor of Nursing ☐ Bachelor of Science in Nursing

☐ Enrolled Nurse ☐ Psychiatric Nurse ☐ Practical Nurse
☐ No credential/degree obtained

☐ Other credential/degree (Explain): ____________________________________________________________________

__________________________________________________________________________________________________

Category of program: ☐ Nursing ☐ Practical Nursing ☐ Psychiatric Nursing ☐ Other

Prescribed length of study for this program:

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Maria Lourna Templa Igsoc ■ CAMIGUIN POLYTECHNIC STATE COLLEGE
Order #: 347258 ■ February 15, 2023 ■ Rev: Aug 2017 ■ Page 2 of 5
How was this program delivered?
☐ On site in class learning ☐ On line distance learning ☐ Blended
☐ Other (Explain): _________________________________________________________________________________
__________________________________________________________________________________________________

Name of the organization that officially recognized, approved, or accredited this nursing program:

Date this nursing program was initially approved or accredited:

(dd/mm/yyyy)

Last date of renewed approval or accreditation:

(dd/mm/yyyy)

NNAS performs a document-based assessment of your student's credentials to Canadian nursing education [and
competency] standards. The quality and completeness of the documents received (i.e. length, depth, breadth) by NNAS
along with this Nursing Education Form greatly influences the degree of comparability. 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 to include with this completed form:

• Official transcript of this applicant's nursing education: This is the official document or record of this
applicant's enrollment, progress and achievement within your education institution. The transcript should
identify courses taken (title and course number), credits and grades achieved, and credentials earned;

• Nursing education program curriculum: a written description of this applicant's program of study and its
individual courses. This can be included digitally (USB drive, CD, etc.);

• Nursing education syllabus for each course: an extremely detailed outline and summary of the topics covered
in each course, including course objectives, learning outcomes and hours of study. Include any document that
would provide supplemental detail to what was taught in your Nursing Program.
NNAS will verify the authenticity of all documents received. If this is the first time your institution is sending
information to NNAS or if you have changed the appearance (stamp, seal, watermark, hologram, etc.) of your
academic records within the past year, please provide a separate document with samples or a description of the
authentic documents along with the names and signatures of the people authorized to submit these materials. In
addition, please provide the name and direct contact information of the official authority for the purpose of
verification.

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Maria Lourna Templa Igsoc ■ CAMIGUIN POLYTECHNIC STATE COLLEGE
Order #: 347258 ■ February 15, 2023 ■ Rev: Aug 2017 ■ Page 3 of 5
 PART C: EDUCATION DOMAIN BREAKDOWN
In addition to attaching a copy of the official transcript of this applicant's nursing education, with a program curriculum and
syllabus for each course, please provide specific contact hours (not credit 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 the
curriculum, please estimate the hours of theoretical instruction and hours of clinical practice in each subject area.
Simulation Clinical Hours
Subject Area Theory Hours
Lab Hours (Direct Patient Care)
Nursing Care of the Adult – Medical
Nursing Care of the Adult – Surgical
Maternal/Infant Nursing
Gynecology
Pediatric Nursing
Gerontology/Geriatric Nursing
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
Current address of this school of nursing/educational institution:
Name:
Address 1:
Address 2:
P.O. Box:
City/Town:
Province/State/Territory:
Postal Code/Zip Code:
Country:
Current address of any affiliated University:
Name:
Address 1:
Address 2:
P.O. Box:
City/Town:
Province/State/Territory:
Postal Code/Zip Code:
Country:

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Maria Lourna Templa Igsoc ■ CAMIGUIN POLYTECHNIC STATE COLLEGE
Order #: 347258 ■ February 15, 2023 ■ Rev: Aug 2017 ■ Page 4 of 5
 PART D: IDENTIFICATION OF OFFICIAL
To be completed by the official authority. Please provide the following information, and spell out all names fully
(no initials or abbreviations). Mail this completed form and all documents directly to NNAS.
Official authorized to provide transcripts

Printed name: Official title:

Phone number: Alternate phone number:
(123-456-7890 format with country code)
Email Address: Website address:

By signing below, I certify all information is true and correct to the best of my knowledge and has been provided by
the appropriate primary source.

Official's Signature: Date Signed:

(dd/mm/yyyy)

[Official signature, date signed, and seal or stamp are required for this document to be accepted.]

In the space to the left, place the official seal or stamp of this organization.

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
Printed name: Official title:
Phone number: Alternate phone number:
(123-456-7890 format with country code)
Email Address: Website address:

By signing below, I certify all information is true and correct to the best of my knowledge and has been provided by
the appropriate primary source.

Official's Signature: Date Signed:

(dd/mm/yyyy)

[Official signature, date signed, seal or stamp are required for this document to be accepted.]
Postal 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
If you have any questions, please contact NNAS via +1 (215) 349-9370.

THIS FORM IS VALID FOR THE BELOW PERSON AND SCHOOL

Maria Lourna Templa Igsoc ■ CAMIGUIN POLYTECHNIC STATE COLLEGE
Order #: 347258 ■ February 15, 2023 ■ Rev: Aug 2017 ■ Page 5 of 5