Doc ID #: DS- 2557844

Nursing Education Form

The following information identifies the applicant to the Nursing School/Educational Institution where education was received.
Ensure this information is correct, then sign and date the form. Provide each populated form to the Nursing School/Educational
Institution to be completed and sent directly to CGFNS by the school.

Part A: Personal Information

ID Number: 8873125 Order Number: 3757244

First/Given Name: John Date of Birth: October 2, 1977
Middle Name: Kyalo Phone Number: (+254) 0780 250242
Last/Family Name: Ndambuki Email Address: [email protected]

Name used when attended this school: John Kyalo Ndambuki

Name of school of nursing/educational institution: Kenya Medical Training College, Nairobi Campus
• Did this school close or merge with another school? N
• If yes, name of institution where transcripts and training records are archived:

Attendance Start Date: September 1999 Attendance End Date: March 2003

I, John Kyalo Ndambuki hereby give my consent to Kenya Medical Training College, Nairobi Campus to provide the
information and documents related to my education requested in this form, and to send this completed form and documents
directly to CGFNS at the following address:

For Standard Mail: For Courier Mail:

CGFNS International, Inc. CGFNS International, Inc.
3600 Market Street, Suite 400 3600 Market Street, Suite 400
Philadelphia, PA 19104-2651 Philadelphia, PA 19104-2651
United States United States

Applicant Signature: ____________________________ Date Signed: ____________________________________

If you have any questions, please contact CGFNS via phone at +1 215-222-8454 or use the Support option in your CGFNS Applicant
Portal.

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 1 of 6
 Part B: Student Education and Credential Information Completed by Authorized Official

To be completed by the official authority. Please provide the following information (in English) concerning
the education of this applicant. Please spell out all names fully (no initials or abbreviations). When sending
this form, please be sure to include the applicant's academic documents required in Part 5.

Do not leave any fields blank; mark questions that are not applicable as N/A.

Part 1: Education / School Information

School Name at Time of Student Attendance:

Current Name If Different from Above:

Address: Country:

Type of Institution: ☐ Secondary ☐ Hospital

☐ Vocational ☐ University / College

Phone Number: Web-Site Address:

Part 2: Student & Credential Information

Student Name on Official Transcript:

Date of Birth (DD/MM/YYYY):

Course of Study: ☐ Nursing ☐ Psychiatric Nursing

☐ Practical Nursing ☐ Other_________________

Name of Credential / Degree

Obtained:

Name in Native Language/Characters (If Different):

Type of Credential: ☐ Diploma ☐ Master's Degree

☐ Certificate ☐ Doctoral Degree
☐ Associate's Degree ☐ No Credential Obtained
☐ Bachelor's Degree ☐ Other: ___________________

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 2 of 6
Part 2: Student & Credential Information (continued)

Date Student Started Program (DD/MM/YYYY):

Name in Native
Language/Characters (If Different):

Did Student Complete Program? ☐ Yes ☐ No

Date Completed or Last Date of Attendance
Graduated (DD/MM/YYYY): (DD/MM/YYYY):
_________________ _________________

Comments:

Part 3: Education Program & Accreditation Information

Program Information

Program Length of Study: Date Began Offering

Program (DD/MM/YYYY):

Minimum Entrance Requirements: Date Stopped Offering

Program (DD/MM/YYYY):

Language of Theoretical Instruction: Clinical Instruction:

Learning Method: ☐ On site in class learning

☐ Online distance learning
☐ Blended
☐ Other: Explain________________________________________

Initial Accreditation/Approval of Education Program

Name of Accrediting/Approving Organization:

Date Initially Approved (DD/MM/YYYY):

Current or Most Recent Accreditation / Approval

Name of Accrediting/Approving Organization:

Date Renewed (DD/MM/YYYY): Date Expires (DD/MM/YYYY):

Level of Accreditation:

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 3 of 6
Part 4: Nursing Education Details
For the subjects listed below, please provide specific contact hours (not credit hours) of theoretical instruction,
lab and hours of clinical practice. If there are no hours, please indicate Not Applicable (NA). Do not combine
subject areas. If they are combined in the curriculum, please estimate the hours of theoretical instruction and
hours of lab or clinical practice in each subject area. All fields are required.
Theory Clinical Lab Independent or
Subject Areas Hours Hours Hours Integrated (Yes or No)

Were theory
and clinical

Independent

Integrated
hours
# or NA # or NA # or NA completed
within 6
months of
each other?
Required

Adult Medical Nursing ☐ ☐

Adult Surgical Nursing ☐ ☐
Obstetrics & Maternal Health ☐ ☐
Pediatric Nursing ☐ ☐
Psychiatric Nursing ☐ ☐
Geriatric Nursing ☐ ☐
Gynecological Nursing ☐ ☐
Primary Health Care ☐ ☐
Community & Public Health
☐ ☐
Nursing
Foundations of Nursing
Anatomy & Physiology
Pathophysiology
Health & Physical
Assessment
Pharmacology & Medication
Administration
Patient Education
Nutrition
Personal & Family Health
Concepts
Human Growth & This Section Left Blank.
Development
Required

Infusion Therapy
Professional Roles &
Functions
Interpersonal Relationships
Leadership & Management in
Nursing
Ethical Considerations
Legal Aspects
Applied Research
Clinical Teaching
Microbiology
Comments:

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 4 of 6
Part 5: Documentation Requirements
***Please provide the following required additional information/documents with this completed form***:

Check if
Check if Not
Included Included Document
Official Transcript (Required)
This is the official document or record of this applicant's enrollment, progress and achievement within your
☐ ☐ education institution. The transcript should identify courses taken (title and course number), credits and
grades achieved, theoretical and clinical hours and credentials earned. In some countries this information
is represented in a Diploma Supplement.

Related Learning Experience (Required for programs located in the

☐ ☐ Philippines)
Related Learning Experience are educational activities and experience that are closely connected to a
specific field of study. Examples include internships, apprenticeships, co-op programs, workshops, or
research projects.
School and University Mark Sheets (Required for programs located in India
☐ ☐ or Nepal)
Mark Sheets are documents that provide a detailed record of a student's academic performance. They
typically list the grades or marks achieved by the student in various subjects or courses.

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 5 of 6
Part 6: Authorized Official Information
To be completed by the official authority. Please provide the following information and spell out all names fully (no
initials or abbreviations). Mail this completed form and all documents directly to CGFNS.

Verified by:

Printed Full Name of Official: Email:

Official Title: Phone Number:

Department:

I certify that I am an Authorized Official and all information is true and correct to the best of my knowledge
and has been provided by the appropriate primary source.

Official's Signature: ______________________________ Date Signed (DD/MM/YYYY): ___________

In the space to the left, place the official seal or stamp of this organization

If the official providing the educational instruction information is a different official, please complete the following.

Official authorized to provide educational information:

Printed Full Name of Official: Email:

Official Title: Phone Number:

Department:

I certify that I am an Authorized Official and all information is true and correct to the best of my knowledge
and has been provided by the appropriate primary source.

Official's Signature: _____________________________ Date Signed (DD/MM/YYYY): ____________

[Official signature, date signed, seal or stamp are required for this document to be accepted.]

Postal Mailing Address By Courier

CGFNS International, Inc. CGFNS International, Inc.
Credentials Evaluation Service (CES) Credentials Evaluation Service (CES)
3600 Market Street, Suite 400 3600 Market Street, Suite 400
Philadelphia, PA 19104-2651 Philadelphia, PA 19104-2651
USA USA

If you have any questions, please contact CGFNS via phone at +1 215-222-8454.

THIS FORM IS VALID FOR THE BELOW PERSON AND AUTHORITY

John Kyalo Ndambuki | Kenya Medical Training College, Nairobi Campus
Order #:o3757244 | Doc ID #: DS2557844 | Page 6 of 6