No Pass, No Pay Change of Contact Form

If you are a new No Pass, No Pay contact for your facility, or will be introducing a new contact, please complete the information below. Once you have completed the form, contact PNCB at npnp@pncb.org to alert them of the change.

Question Title

* 1. Employer Information

Hospital/Employer:

Requested Effective Date of Change:

Question Title

* 2. Are you a new/additional program contact? Or are you replacing a current contact?

New/Additional Contact

Replacing a current contact (please specify who)

Question Title

* 3. New Primary Contact Information
At least one individual is required to be designated as the Primary Contact Person for your organization's No Pass, No Pay Program. Please provide the following information:

Full Name: *

Title: *

Address 1: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

Question Title

* 4. Do you agree to have oversight for the No Pass, No Pay Program at the employer level? Responsibilities include:

Share code with eligible nurses

Monitor weekly interim reports of nurses who apply using the code

Notify PNCB within 2 business days of interim report receipt of nurses no longer eligible (e.g., terminated, gave notice)

Promote information about the CPN exam and how to apply

Read email updates regarding CPN (usually less than 1 email per month)

Question Title

* 5. I understand my duties as a No Pass, No Pay program contact. PNCB will follow up for any questions about the program during your transition.

Full Name (Serves as Signature):

Date:

Question Title

* 1. Employer Information

Question Title

* 2. Are you a new/additional program contact? Or are you replacing a current contact?

Question Title

* 3. New Primary Contact InformationAt least one individual is required to be designated as the Primary Contact Person for your organization's No Pass, No Pay Program. Please provide the following information:

Question Title

* 4. Do you agree to have oversight for the No Pass, No Pay Program at the employer level? Responsibilities include:

Question Title

* 5. I understand my duties as a No Pass, No Pay program contact. PNCB will follow up for any questions about the program during your transition.

* 3. New Primary Contact Information
At least one individual is required to be designated as the Primary Contact Person for your organization's No Pass, No Pay Program. Please provide the following information: