Arizona State Board of Nursing - Death Certificates Evaluation

My Services

Renew your RN/LPN license, purchase a duplicate or update information online using My Services.

NOTICE: Effective January 1, 2008, based on Federal and State Laws, all applicants must provide evidence of citizenship or nationality.

NOTICE: CNA Online Renewal is offline until further notice.

Death Certificate Education Evaluation Form

In order to complete the Death Certificate Education Evaluation Form you must first verify your information using the form below.

Identification Information

Last Name	•
Social Security Number	- - •
Date of Birth	/ / •

Please check the box next to the number that most accurately describes your opinion of how well the course met the objectives.

1 = Poorly; 2 = Needs improvement; 3 = Adequately; 4 = Very well

This course prepared me to:

1) Accurately and completely document the immediate cause of death and any diseases, injuries, or complications that gave rise to the immediate cause of death.

1 2 3 4

2) Accurately and completely document other important diseases that were present at the time of death and may have contributed to the death of a patient.

1 2 3 4

3) Recognize and report to the medical examiner deaths that are legally required to be reported, including deaths where elder abuse or child abuse occurred.

1 2 3 4

4) Recognize and report to the Center for Disease Control, diseases and conditions that are legally required to be reported.

1 2 3 4

5) Recognize situations that require the completion of a fetal death certificate and accurately and completely document fetal death.

1 2 3 4

6) Adhere to the time-frames in which the death certificate must be filed according to Arizona law.

1 2 3 4

7) Develop an awareness of the therapeutic benefit to grieving families of an accurate, and complete certification of death.

1 2 3 4

8) Please describe any suggestions for improving the module.

9) I attest that I have read the required materials in the education module, Completing the Death Certificate Education Module for Nurse Practitioners.

Yes No

To submit the form, click ONCE on the "Submit Evaluation" button. It will take a
moment for the form to process and then you will be taken to a confirmation page.