Center for Nursing Education and Testing (C-NET)

35 Journal Square, Suite 901

Jersey City, New Jersey07306

Phone: 800-463-0786 x14

Fax: 201-217-9785 (Attn: Ms. Nugent)

E-mail:

Medical-Surgical Nursing Certification Examination

Special Test Site APPLICATION

This application form is a request to host the Medical-Surgical Certification Exam on site at a Hospital or Facility. It must be completed by the individual who will serve as contact person for the temporary exam site. By filing this application you agree to take full responsibility for the testing conditions at your exam site.

Toproperly complete your application to create a Special Test Site:

Print out and complete application.
Include $300.00 site fee w/ application. Visa & Mastercard ONLY or Check (if mailing in application).Applications only accepted with payment.
Submit application to C-NET using the information listed at the top of this application for email, fax, or mailing address. If mailing your application, make sure your postmark is at least 1 week before the deadline.
You will be notified via e-mail that we have received your application after the deadline has passed. You may call or e-mail if you desire earlier confirmation.

(Please print clearly)

TEST SITE INFORMATION

Exam Site Facility Name: ______

(Full name please-no abbreviations)

Exam Site Address: ______

(Street address)

______

(Street address 2)

Roomname/number: ______

City: ______State: ______Zip: ______

SITE CONTACT INFORMATION

Site Contact Name: ______

Contact Address: ______

(Street address)

______

(Street address 2)

City: ______State: ______Zip: ______

H Phone: ( )______W Phone: ( )______

Cell / Pager: ( )______Fax : ( )______

(please circle one)

Email: ______

You MUST check one of the following two options:

□I would like to close my Special Test Site to restrict it to our staff only.

NOTE: You must include the name(s) of the Hospitals/Facilities that may apply to your staff only site

The Hospitals and/or Facilities whose staff may apply for this staff only site are:

______

□I would like to open my Special Test Site to nurses from other facilities.

NOTE:If you choose this option you may not limit the number of applicants for your site. You must provide space for all that apply (rarely do special test sites exceed 40 people, 10-20 on the final roster is average).

------

PAYMENT SECTION

I will be paying by:

□Check (Enclosed, payable to C-NET)

□Credit Card #: ______І______І______І______І Exp. Date ____/_____

□Visa □ Master Card Name on Card: ______

□My fee was held from previous test date of October 15, 2016.

Thank you for your interest in our exams! For more informationplease visit our website: ‘ You will find a Special Test Site FAQ as well as more information about the variety of services C-NET® provides.

Basic responsibilities of the Site Contact/Exam Manager of Special Test Site

Site Contact Duties:

Complete and submit Special Test Site application
Reserve a room in the facility to host the exam in keeping with the physical arrangements guidelines provided in of this document.
Work with C-NET Staff via email/phone if neededto coordinate the Special Test Site.
Articulate to your staff: Nurses should familiarize themselves with policies, procedures and deadlines as they relate to their registration for the CMSRN.

Exam Manager Duties:

Provide C-NET staff with their mailing address & contact information.
Receive the shipment of the exam materials & confirming their arrival and completeness.
Keep the exammaterials locked away until the day of the exam.
On the appointed exam day, being the materials to the Special Test Site.
Check examinees in to the test site & administer the exam according to instructions in the Exam Manager’s manual (in the exam materials shipment).
Appointing a proctor to act as an assistant to the Exam Manager.
After the exam time ends, organize the exam materials & mailing them back to C-NET for in accordance with procedures outlined in the Exam Manager manual.

Physical Arrangements for Certification Exams at Special Test Sites

Adequate physical arrangements for the exam help to create a favorable attitude toward the test among the candidates. Maximizing candidates’ comfort and freedom from disturbance helps them do their best work on the test. In contrast, a poor test environment can interfere with the candidates' performance. Problems with noise, inadequate lighting, or an uncomfortable room temperature can lead candidates to challenge the results of their test performance. In these cases, the candidates must be retested at no cost and at their convenience--which increases the cost of testing for everyone.

You should independently confirm the physical arrangements for the examination well in advance of the test administration and make a site visit, if necessary. Prior to the examination, you should also identify someone from the facility who can assist with environmental problems on exam day (e.g., temperature, noise, additional chairs), should they arise.

Set-up of Examining Room. Sufficient space for the examination must be provided, with each candidate separated from the next candidate by an empty seat. When the exam is given in a classroom in an educational institution, it is also advisable to keep an empty row of chairs between candidates (Figure 1). If the chairs are movable, and there is not enough space to allow for an empty row of chairs between candidates, the chairs should be moved to be as far apart as possible.

As a general rule, two candidates can sit at a table that is six feet long, and three candidates can sit at a table that is eight feet long. If candidates need to sit in every row of tables, the candidates should sit directly behind one another, to minimize the likelihood of seeing the answer sheet of a person sitting in the row ahead.

CHECKLIST:

Recommended Physical Arrangements

The following must be available:

•A directory or sign(s) clearly indica-ting the location of the test. C-NET will issue exam permits that list the address of your site, but the exact location of the testing room may be difficult to find at large medical centers, universities, and hotels.

•A table placed at the entrance/exit, for registration of the candidates for the examination.

•A large table at the front of the room for holding the examination materials prior to distribution and following the test.

•A place to check coats, hats, and other materials brought to the exam site. Pocketbooks, books, notebooks, etc., can usually be placed underneath the candidates' tables. The candidates should have only the test materials and their exam permits on the table, with the exception of tissues, candy, water, cough drops. etc., at the discretion of the exam manager.

•Good lighting, ventilation, comforta-ble temperature, and freedom from outside noise.

•Sufficient room for spacing candi-dates, ideally, with each candidate separated from the next candidate by an empty seat.

•Adequate writing surface and enough space for the candidates to open their booklets, which measure 11" by 17" when opened, and to lay their answer sheets flat (8 1/2" by 11").

•Provision for left-handed candidates. At times, it may also be necessary to make accommodations for disabled candidates, e.g., a person in a wheel-chair with a casted leg. If special accommodations are needed, candidates must notify C-NET in advance so that we may notify the exam manager prior to the test date.

•Comfortable chairs.

•A large clock. If no wall clock is available, a large-faced clock can be used, or the time may be written on a chalkboard or flip chart every 30 minutes.

•A microphone, if the number of candidates and size of the room make it necessary to amplify the exam manager's voice.

•Accessibility to a water fountain, rest room, and a telephone (for exam manager and proctors, only). No official "breaks" are permitted during the examination, and no refreshments are to be offered by the exam manager or proctor(s) during the examination. If an emergency occurs in which a candidate must make or answer a phone call, the candidate must be accompanied to the phone by a proctor.

Figure 1. Classroom Arrangement for Certification Examination



Empty row



Empty row

Note. The empty boxes are the chairs where candidates are seated.