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Program Closure Notification Form
Please complete this form for each program code that is closing
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* Indicates required question
Email
*
Your email
Name of person completing this form
*
Your answer
Phone number of person completing this form
*
Your answer
School Name
*
Your answer
Program Code (One program per form):
*
Your answer
Program Type
*
ADN
ADN-PN Option
APRN
APRN DISTANCE LEARNING
APRN DISTANCE LEARNING-APPROVED BY HOME STATE
BSN
BSN DISTANCE LEARNING
CMA~Medication Assistant
CNA~Nursing Assistant
CRNA
MSN
MSN DISTANCE LEARNING
PN
REFRESHER PN
REFRESHER PN DISTANCE LEARNING
REFRESHER RN
REFRESHER RN DISTANCE LEARNING
Required
Date the last class completed:
*
MM
/
DD
/
YYYY
Number of students graduated in that class:
*
Your answer
Program closure date:
*
MM
/
DD
/
YYYY
Address where student records will be kept:
*
Your answer
Contact NAME for the person AZBN should direct students to if they contact us about their records while in your program?
*
Your answer
EMAIL for the person AZBN should direct students to if they contact us about their records while in your program?
*
Your answer
PHONE NUMBER for the person AZBN should direct students to if they contact us about their records while in your program?
*
Your answer
Do you have any attachments you would like to submit? If so, we will contact you after receiving this form.
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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