Verification of Theory and Clinical Instruction Form - CT.gov 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and social security number in the designated fields at the top of the form.
3. Fill in the name of your school and country, followed by the enrollment dates indicating when you started and completed your program.
4. In the section for educational institutions, ensure that the total months and hours of your practical nursing program are accurately recorded, including supervised direct client care experiences.
5. Indicate whether you received a degree, diploma, or certificate in nursing by selecting 'Yes' or 'No'. If applicable, provide an explanation if you did not complete the program in good standing.
6. Finally, have an authorized representative from your educational institution sign and date the form, along with their contact information.

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