KANSAS STATE BOARD OF NURSING

LANDON STATE OFFICE BUILDING

900 SW JACKSON, SUITE 1051

TOPEKA, KS 66612-1230

Continuing Education Annual Report

Name of Provider
Provider Number (for Renewal)
Legal Body (if different from provider)
Address of Provider

Telephone
E-Mail Address
Program Coordinator
Reporting Year:

Interactive Offerings

Total Number of Offerings
Total Number of offering Contact Hours: Sum of all contact hours presented
Total Number of APRN Participants
Total Number of RN Participants
Total Number of LPN Participants
Total Number of LMHT Participants

Offering Contact Hours taught by: Sum of OH taught by each category total should be the same as :Total Number of Offering Contact Hours"

Nurses
Others

Independent Study Offerings

Complete only if you offer Independent Study

Number of Independent Study topics offered:
Total Number of Independent Study Contact Hours: Sum of all contact hours for IS topics
Total Number of APRN Participants
Total Number of RN Participants
Total Number of LPN Participants
Total Number of LMHT Participants

Attestation
I realize that this application is a legal document and by pressing the Submit button you are 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.

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