Certification Equivalency Request

Use this form to enter information regarding your education, work experience, and continued professional development activities.
The information you enter will be used by the Equivalency Review Committee to determine if the combination of what is submitted
meets the intent of the eligibility requirement for the bachelor's degree for the CHSE and CHSOS certifications.
All items with a * are required.
Please enter all pertinent data completely and accurately.

APPLICANT DATA

Last Name *

First Name *

Email Address *

Country *

Requesting Equivalency for: *

Bachelor's Degree (CHSE)

Bachelor's Degree (CHSOS)

EDUCATION

In this section, enter all education COMPLETED at an accredited college or university.
Include any conferred degrees as appropriate. This would also include coursework that has been completed
but did not conclude with a degree being conferred.

Institution #1

Start Date

End Date

Field of Study

Semester Hours Completed

Degree Received (or enter none)

Institution #2

Start Date

End Date

Field of Study

Semester Hours Completed

Degree Received (or enter none)

Institution #3

Start Date

End Date

Field of Study

Semester Hours Completed

Degree Received (or enter none)

ADDITIONAL EDUCATION ACTIVITIES

In this section, enter all other educational activities for which you received a certificate for completing a prescribed
course of activities from a specific entity (agency, company, program) and believe you should receive credit.
These should be items related to healthcare simulation such as certficate courses, medical licensure (that is not a degree above),
military programs, technical courses, technology courses, simulation specific courses (e.g. vendor course).
NOTE: this does not include attendance at conferences. Please see associated documentation on the website for clarification.
Please enter all pertinent data completely and accurately.

Activities (list any item with
dates and relevance)

WORK EXPERIENCE

In this section, enter all work experience that is relevant to the certification (e.g. CHSOS) for which you are applying.
This should be employment related to healthcare simulation such as in the clinical, healthcare simulation, simulation technology,
or similar type of settings. The employment should have contributed to preparing you for your healthcare simulation duties.
Please see associated documentation on the website for clarification.
Please enter all pertinent data completely and accurately.

Employer #1

Start Date

End Date

Job Title

Brief Description of Job
(250 character limit)

Healthcare Simulation Relevance
(250 character limit)

Employer #2

Start Date

End Date

Job Title

Brief Description of Job
(250 character limit)

Healthcare Simulation Relevance
(250 character limit)

Employer #3

Start Date

End Date

Job Title

Brief Description of Job
(250 character limit)

Healthcare Simulation Relevance
(250 character limit)

ADDITIONAL INFORMATION

In this section, include any additional information that is not entered above. The purpose of this section is to
ensure that all relevant information for your equivalency has been captured. Please be sure to describe the relevance of
any information that is entered.

Additional Information
(include relevance)

Please attach your resume or CV to this form prior to submitting. *

* = Input is required