ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
2
Ordinary Member Examination Applicants Vetting Checklist
3
4
5
6
Name:
Present Working Place:
7
8
Admission Criteria
9
1
Self-declaration on no criminal conviction or professional misconduct
YES
10
2
Valid RN Registration Certificate
YES
11
3
Valid RN practicing certificate
YES
12
4
Holder of Master Degree in Nursing or Master in Related Specialty
YES
13
5
Valid Certificate on related Specialty training
YES
14
6
Specialty : _______________________________ Year obtained_____________
15
7
Complete Surgical Nursing Training (SNT) Part A
YES
16
8
Complete Surgical Nursing Training (SNT) Part B
YES
17
9
Working Experience ( accumulate 4 years in the specialty in the most recent 6 years)
18
From (MM/YY)
To (MM/YY)
Sub-Total (MM/YY)
19
///
20
///
21
///
22
23
Grand Total Months Years
24
(From_______________To______________)
25
26
10
Specialty Training
27
● Certificate Attached
Yes
28
● Logbook Attached
Yes
29
Remarks: Master Degree in Nursing + SNT Part B (500 hrs. theory + > 500 hrs. Clinical Practicum)
30
OR Master in related specialty + > 500 hrs. Clinical Practicum + specialty logbook signed within
31
 4 years
32
33
34
35
36
10.1
Academic Experience(500 hours)
37
● structured courses at post-graduate level (60-100%)
38
● structured courses provided by specialty course providers (0-40%)
39
10.1.1
Generic core (167 hours )
40
CourseHours
41
CourseHours
42
CourseHours
43
CourseHours
44
CourseHours
45
CourseHours
46
CourseHours
47
CourseHours
48
49
Grand Total
Hours
50
51
10.1.2
Advanced Practice core (167 hours)
52
CourseHours
53
CourseHours
54
CourseHours
55
CourseHours
56
CourseHours
57
CourseHours
58
CourseHours
59
CourseHours
60
61
Grand Total
Hours
62
63
64
10.1.3
Specialty core (167 hours)
65
YearCourseHours
66
YearCourseHours
67
YearCourseHours
68
YearCourseHours
69
YearCourseHours
70
YearCourseHours
71
YearCourseHours
72
YearCourseHours
73
Grand Total
Hours
74
75
10.2
Clinical Experience (500 hours)
76
10.2.1
Guided clinical practice (50-100%)
77
Weeks =Hours
78
Weeks =Hours
79
Weeks =Hours
80
10.2..2
Work placement (0-50%)
Weeks =Hours
81
Weeks =Hours
82
Weeks =Hours
83
Grand Total
Hours
84
85
11
Approved for sitting examination
YESNO
86
11.1
Follow up with supplementary information required
87
1
88
2
89
90
Endorsed by HKCSN Administration & Registration Committee
91
___________________________________
___________________________________
92
(Signature / Name )
(Signature / Name )
93
Date ____________________
Date ____________________
94
95
96
97
98
99
100