Doctor of Nursing Practice
Scholarly Project
Planning Form
PART A – STUDENT INFORMATION (Please type or print.)
Student Name ___
Complete Permanent Address ___
Street or P.O. Box
Street or P.O. Box
City State Zin Code
City State Zip Code
Contact Information (with area codes): Home Phone___
Work Phone _____ Cell Phone _____
E-Mail Address ___
RN License ___
Number State Expiration Date
Other contact information_____
……
___ DATE
STUDENT'S SIGNATURE
DATE
2023
FACULTY'S SIGNATURE
DATE
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Office Use Only
Date Processed at KSU SON and support staff name _____
RN Licensure verified___
CPR Certification verified