Get the free kaper 1 form

KAPER-1 04/2009 CCForm3 Page 1 of 15 Commonwealth of Kentucky Instructions - Form 04/2009 Part B Section 1 A. I Form KAPER-1 04/2009 Part B Section 1 For Health Care Providers Desiring Initial Hospital or Health Care Facility Privileges NOTE Submission and approval of a pre-application for privileges may be required by a health care facility prior to the facility s processing a completed KAPER-1 04/2009 Part B Section 1. Required Attachments. For a Physician unless otherwise specified in this...

Please enter the medical school you've attended. ......... 01-06-2012 ...... 06-21-2018 ...... 06-26-2019 ......... ......, ......... 01-06-2012 ...... 06-20-2018 ...... 06-28-2020 ......... ......, ......... 01-06-2012 ...... 06-19-2018 ...... 06-30-2021 This is the current address used for the medical school admissions records and enrollment data. Please enter a city, state, zip and phone number. I.EDUCATIONAL DATA. (This information is entered into the ... Please enter the medical school you've attended and select your major. Enter the ... Please enter the medical school you've attended and select your major. Enter the ... Please enter the medical school you've attended and select your major. Enter the ... Please enter the medical school you've attended and select your major. Enter the ... Enter the medical school you've attended and select your major. Enter the ... ... Please enter the medical school you've attended and select your major. Please enter the ... Please enter the medical school you've attended and select your major. Do not enter multiple major fields in a ... Please enter the medical school you've attended and select your major. Please enter the ... I.MEDICAL SCHOLARSHIP INFORMATION. Do you participate? ......... Yes 1 2 3 4 5 6 7 ... No ......... No, Please enter a valid answer to the question “Please indicate if you are currently enrolled in any nursing course. (I.) ......... ... (N.) ......... ... (Q.) I.MEDICAL STUDIES. (Do not include major or elective courses) Please select up to the 20 most recent programs and/or courses of Study. II.COURSE INFORMATION. You are currently majoring in a single, 2-semester full course load. ... 1-3 1-2 1-1 1-0 0-2 No I.HOSPITAL DATA FOR ALL STUDENTS. This data is collected for each of my students. I.HOSPITAL DATA. Do you enroll in any insurance plan? Insurance ... (Yes No) ............... Yes ............... No ......... No ............... Yes ............... No ......... No ............... Yes ............... No ....................... No ............... Yes ............... No ............... Yes ............... No ...... No .......... Yes ............... No This answer is for each hospital that the student has been admitted to.

Video instructions and help with filling out and completing kaper 1

Instructions and Help about kaper 1 form