Primary Instructor [18 VAC 90-26-30.B.&D.]
1.Name:______Virginia R.N. license #:______
Or Compact State and License #:______
2.List work experiences in the last 5 years as a Registered Nurse and RN experience in long term care at any time in
your RN career.
DatesFrom To / Employer, Address &
Phone Number / Type
Facility / Type
Clients / Duties/Responsibilities
3. Competence to teach adults
a. Course(s) beyond basic nursing education taken and completed in principles and methods of
adult learning.
DatesFrom To / School & Location / Course Title &
Description / Clock Hours / Credit Hours
or C.E.U.S.
Train-the-Trainer for Nurse Aide
Instructor – include dates of attendance
And copy of completion certificate
b. Experience in teaching adult learners within the past five years.
DatesFrom To /
Adult Learner
Population(s) Taught / Agency & Location / DutiesOther Instructional Personnel (Registered Nurse) [18 VAC 90-26-30.C.&D.]
1.Name:______Virginia R.N. License #:______
Or Compact State and License #:______
2.Direct patient care experience as an R.N. for the past five years.
DatesFrom To / Employer, Address &
Phone Number / Direct Patient Care
Experience
3.Competence to teach adults:
a. Course(s) beyond basic nursing education taken and completed in principles and methods of
adult learning.
DatesFrom To / School & Location / Course Title &
Description / Clock Hours / Credit Hours or
C.E.U.S.
Train-the-Trainer for Nurse Aide
Instructor – include dates of attendance
And copy of completion certificate
b. Experience in teaching adult learners within the past five years.
DatesFrom To / Adult Learner
Population(s) Taught / Agency & Location / Duties
Other Instructional Personnel (Licensed Practical Nurse) [18 VAC 90-26-30.C.&D.]
1.Name:______Virginia L.P.N. License #:______
Or Compact State and License #:______
2.Direct patient care experience as an R.N. for the past five years.
DatesFrom To / Employer, Address &
Phone Number / Direct Patient Care
Experience
3.Competence to teach adults:
a. Course(s) beyond basic nursing education taken and completed in principles and methods of
adult learning.
DatesFrom To / School & Location / Course Title &
Description / Clock Hours / Credit Hours or
C.E.U.S.
Train-the-Trainer for Nurse Aide
Instructor – include dates of attendance
And copy of completion certificate
b. Experience in teaching adult learners within the past five years.
DatesFrom To / Adult Learner
Population(s) Taught / Agency & Location / Duties
May 2015