INTERNATIONALLY EDUCATED APPLICATION FOR REGISTRATION … · INTERNATIONALLY EDUCATED NURSES APPLICATION ... if you have any outstanding questions send ... application for registration

INTERNATIONALLY EDUCATED NURSES APPLICATION FOR REGISTRATION Revised December 19, 2017 Page 1 of 2

INTERNATIONALLY EDUCATED NURSES APPLICATION FOR REGISTRATION

Below is a brief description of what is required to begin the application and what to expect throughout the process. Please read through carefully. Once you’ve reviewed the forms in their entirety, if you have any outstanding questions send them to [email protected].

MANDATORY FORMS TO RETURN DIRECTLY TO CLPNA (DO NOT SUBMIT NNAS ADVISORY REPORT)

Application for Registration Form: The application can be submitted by mail or email.

Resume: Must include all previous nursing employment, with dates and position(s) held and can be submitted by mail or email.

Criminal Record Check: I have completed my Criminal Record Check with myBackCheck at https://www.sterlingtalentsolutions.ca/clpna/ within the last 6 months.

Job Description(s): Must be provided to the CLPNA directly from the previous employer(s) by mail.

Self-Assessment: Must include details of where, when and how the skill was obtained/ performed and can be submitted by mail or email.

METHODS OF SUBMISSION

Mail: St. Albert Trail Place, 13163-146 Street Edmonton, Alberta T5L 4S8 CANADA

Email: [email protected]

TIME FRAMES (BRIEF OUTLINE OF WHAT TO EXPECT)

Confirmation of Application Receipt: Applicants will receive an email confirming the receipt of their application within 5 business days along with a receipt for the Application fee.

Assessment: Once an application package is complete, it will be forwarded to the Registrar for assessment. This process can take up to 20 business days. Once the results of the assessment are available, they will be sent to applicants by email with next steps.

Request for Information Review (not applicable to every applicant): If an applicant is sent a Request for Information email, the information will be reviewed by the Registrar once it is received. An email with next steps will be sent within 20 business days of its receipt.

Temporary Registration: Once an applicant is approved for Temporary Registration they will need to submit the forms that were sent with their assessment results. Once these forms are received, they will be processed within 5 business days and applicants will be sent an email with next steps.

CPNRE: Once you have obtained Temporary Registration, you may be eligible to take the CPNRE, more information and next steps will be sent to applicants once their Temporary Registration is processed.

FEE SCHEDULE

Application Fee $340.00 Temporary Registration & CPNRE Fee $650.00 (this fee is paid once applicant is approved for Temporary Registration) The CLPNA decreases the temporary registration fee for permits issued after August 1.

ADDITIONAL FINANCIAL INFORMATION

Registration fees are not refundable, non-transferable.

Payments are to be made payable to CLPNA and prices are subject to change. (NO personal cheques).

Payment methods: o Visa/ MasterCard (fill out form attached) o Money Order or Certified Cheque o Cash or Debit (in CLPNA Office)

Temporary Registration Permits expire annually on December 31st.

https://www.sterlingtalentsolutions.ca/clpna/

mailto:[email protected]

INTERNATIONALLY EDUCATED NURSES APPLICATION Revised December 20, 2016 Page 2 of 2

INTERNATIONALLY EDUCATED NURSES APPLICATION FOR REGISTRATION Revised December 19, 2017 Page 1 of 4

INTERNATIONALLY EDUCATED NURSES APPLICATION FOR REGISTRATION

PERSONAL (Please Print)

Current Legal Surname (Last Name) Given Name (First Name) Middle Name(s)

Maiden Name Date of Birth (dd/mm/yy) Sex Female Male

Apartment / Box No. / Address or Street No. City / Town / Village

Province/State Country Postal Code / Zip Code

Telephone No. Cell No. Primary Language

E-mail Address (MANDATORY) NNAS ID Number NNAS Application ID Number

CRIMINAL RECORD CHECK Effective April 1, 2018 the CLPNA has partnered with BackCheck to complete the Criminal Record Checks on behalf of the CLPNA. In order to meet the requirements of registration the CLPNA will only consider Criminal Record Checks issued by BackCheck directly to the CLPNA through the online system. To register for an account and complete your Criminal Record Check visit: https://www.sterlingtalentsolutions.ca/clpna/ Criminal Record Checks are considered valid for 6 months from the date of issue

PERSONAL DECLARATION (check applicable answer) For more information on the CLPNA’s authority to request an applying member to self-declare, visit www.clpna.com; Practice Policy - Personal Declaration for Registration Requirements which is linked to three supportive documents to enhance the LPN’s understanding of Interpretive Document-Duty to Report, Interpretive Document-Fitness to Practice and Incapacity, and Practice Guideline-Preventing Nurse-to-Client Transmission of Blood-Borne Virus and Other Communicable Diseases.

1. Have you ever applied for registration in Alberta before? Yes No

2. Have you applied for registration in any Canadian province or territory? Yes No

3. Have you ever been denied registration/licensure by a registration/ licensing authority for nursing in Alberta or any other any other health profession in Alberta or any other province, territory, state or country?

Yes No

4. Have you ever been subject to any investigative proceedings with respect to unprofessional conduct, incompetence, or incapacity in nursing or any regulatory body, in Alberta or any other province, territory, state or country?

Yes No

5. Are you currently under investigation, or involved in any proceedings, which could or has resulted in the encumbrance of your nursing registration by

a. A registration/licensing authority for nursing LPN/RPN/RN in any province, territory, state or country? Yes No

b. Another health profession (other than nursing) in any province, territory, state or country? Yes No

c. Any other profession in any province, territory, state or country? Yes No

6. Are you currently charged with a criminal offense? Yes No

7. Have you pleaded guilty or been found guilty of a criminal offence for which a pardon has not been granted? Yes No


http://www.clpna.com/


8. Do you have any physical or mental condition or disorder that may impair your ability to provide safe, competent and ethical care? Do not answer the last two questions if you have not answered yes to this question.

Yes No

a. If “Yes”, are you under the care of a physician or healthcare team? Yes No

b. If “Yes”, are you following medical advice? Yes No

(Please Print: If you answered ‘YES’ to any question on the Personal Declaration, provide a brief explanation.)

NURSING EMPLOYMENT INFORMATION (Please Print) Please indicate your previous 2 nursing positions (registered nurse, licensed practical nurse) held within the last 4 years. Nursing positions listed must have been reported to the NNAS and indicated on your advisory report. If have not practiced as a nurse within the past 4 years please leave this section blank. You are required have your previous employer(s) provide an original job description directly to the CLPNA. The job description must come in a sealed envelope directly from the place of origin.

________________________________________________________ Facility Name

________________________________________________________ Position Held (Registered Nurse/Licensed Practical Nurse)

______________________________________ Name of Supervisor

____________________________________ City/Town/Village

_____________________________________ Country

______________________________________ Supervisor Email Address

____________________________________ Telephone No.

_____________________________________ Dates of Employment

NURSING EMPLOYMENT INFORMATION (2nd Employer)

________________________________________________________ Facility Name

________________________________________________________ Position Held (Registered Nurse/Licensed Practical Nurse)

______________________________________ Name of Supervisor

____________________________________ City/Town/Village

_____________________________________ Country

______________________________________ Supervisor Email Address

____________________________________ Telephone No.

_____________________________________ Dates of Employment

APPLICATION CHECKLIST I have included the $340.00 non-refundable application fee. (Visa/MasterCard payable on the credit card authorization form, certified cheque or money order payable to CLPNA. Please do not mail cash.

I have included my resume, describing my education, experience, and employment history.

I have completed my Criminal Record Check with myBackCheck at https://www.sterlingtalentsolutions.ca/clpna/ within the last 6 months.

I have requested my previous employer(s) to submit an original job description directly to the CLPNA.

I have submitted the self-assessment form and provided detailed information as to where the attribute was learned.



PRIVACY STATEMENT I acknowledge that the information contained in this form is being collected and will be used for the purpose of assessing my application for registration. This information will be maintained on my file and may also be used to assess my application for renewal of my practice permit in the future or for the purpose of a discipline proceeding under Part 4 of the Health Professions Act. The information contained in this form will only be disclosed pursuant to the provisions in the Health Professions Act, the Personal Information Protection Act, as otherwise required by law, unless your consent to disclose the information has been obtained. DENY OR DEFERRAL OF REGISTRATION ELIGIBILITY I acknowledge that the College may immediately deny or defer registration if any information contained in this application is inaccurate or incomplete until such time that the College has had the opportunity to reconsider my application. I agree to provide any additional information that may be required by the College to consider my application for registration. REGISTRATION DECLARATION I declare that all of the information on this form is current, correct and complete. I declare that all documents submitted with this application to the College are authentic true originals or true copies of original documents. I declare that I am of good character and am fit to practice, consistent with the responsibilities, ethics and standards expected of a Licensed Practical Nurse. I hereby certify that I am the person making application for registration as a Licensed Practical Nurse in Alberta and that all statements are true and complete in every respect. I understand that omission, inaccuracy, and falsification of information on this application may result in the cancellation of my application for registration or cancellation of any registration, which may be issued. I understand that my application for assessment of eligibility and/or registration is considered lapsed if required documentation is not received in the CLPNA office and I have not obtained registration within one (1) year from my application date. I understand that after the year has lapsed I am required to reapply.

_______________________________________________________ Applicant Signature (do not print)

_______________________________________________________ Date (dd/mm/yy)

Submit completed application to [email protected]

mailto:[email protected]


PAYMENT INFORMATION (please print)

Date: Amount: $340.00

Payment Description: Application Fee

PERSONAL INFORMATION (please print)

Name:

Address:

City: Province: Postal Code:

Phone: Fax:

Email:

INTERNATIONALLY EDUCATED – APPLICATION FEE CREDIT CARD AUTHORIZATION FORM

For privacy and security reasons, once payment is processed the below section will be destroyed.

CREDIT CARD INFORMATION (please print)

Cardholder Name:

Credit Card #:

Expiry Date: Month: Year: Credit Card: VISA MasterCard

Signature: Date:

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INTERNATIONALLY EDUCATED NURSES

SELF-ASSESSMENT FOR INTERNATIONALLY EDUCATED NURSES

NAME: ____________________________________________ STAKEHOLDER NUMBER:____________

SELF-ASSESSMENT RATING SCALE

1 - Always 2 - Sometimes 3 - Never

I performed this task daily in my previous position. I am comfortable with my knowledge, skills and abilities as related to this task/requirement.

I occasionally performed this task in my previous position. I am somewhat comfortable with my knowledge, skills and abilities as related to this task/requirement.

I never performed this task in my previous position. I am not comfortable with my knowledge, skills and abilities as related to this task/requirement.

Rate each of the following on a scale of 1-3 as per the rating scale above.

Competency Rating (1-3)

Demonstrates knowledge of therapeutic communication.

Where, when and how I demonstrated this skill: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________

Initiate and maintain a therapeutic environment, including use of therapeutic communication techniques.

Where, when and how I demonstrated this skill: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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SELF-ASSESSMENT FOR INTERNATIONALLY

EDUCATED NURSES Utilize the nursing process (assessment, planning, implementation and evaluation) to apply knowledge and theory in the provision of care.

Where, when and how I demonstrated this skill: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Uses a theory-based approach.


Demonstrates knowledge in nursing, health and social sciences.

Where, when and how I demonstrated this skill: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Complete assessments using a systematic approach in a holistic (bio-psycho-social and spiritual) manner.

Where, when and how I demonstrated this skill: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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EDUCATED NURSES Implements identified health teaching strategies into clients’ learning.


Make clinical judgments based on different ways of knowing, including critical thinking and intuition.

Where, when and how I demonstrated this skill: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________

Incorporates the determinants of health and health disparities/inequities into all aspects of care.


Considers the determinants of health during all aspects of care.

Where, when and how I demonstrated this skill: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________

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EDUCATED NURSES Care for clients at any point in the life cycle employing a systematic approach and holistic (biological, psychological, spiritual, developmental and sociocultural needs) perspective in the completion of nursing care.

Where, when and how I demonstrated this skill: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Sensitive to client cultural diversity (eg age, socio-economic, cultural, ethnic, gender ability) in assessment, planning, implementation and evaluation of nursing care.

Where, when and how I demonstrated this skill: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Collaborates with clients across the lifespan to perform a holistic nursing assessment.


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EDUCATED NURSES Adhere to Code of Ethics.


Respects and preserves clients’ rights based on a code of ethics or ethical framework.


Recognizes and reports situations within the practice environment that are potentially unsafe.


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EDUCATED NURSES Demonstrates behaviours that contribute to an effective and therapeutic nurse-client relationship.


Engages in relational practice through a variety of approaches that demonstrates caring behaviours appropriate for clients.


Demonstrates support for clients making informed decisions about their health care, and respects those decisions.


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EDUCATED NURSES Respects clients’ diversity and decisions.


Provides care for clients while being respectful of diversity.


Uses self-awareness to support compassionate and culturally safe client care.

Where, when and how I demonstrated this skill: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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EDUCATED NURSES Demonstrates knowledge of the distinction between ethical responsibilities and legal rights and their relevance when providing nursing care.


Respect clients’ directives, right to self-determination and right to informed decision-making.


Advocate for equitable access, treatment and allocation of appropriate resources within the community for all clients.


Uses an ethical reasoning and decision making process to address situations of ethical distress and dilemmas.


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EDUCATED NURSES Recognize and fulfill the professional obligation of the duty to provide care.


Advocate for client autonomy, respect, dignity and access to information, especially when they are unable to advocate for themselves.

Where, when and how I demonstrated this skill: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Advocates for clients’ rights especially when they are unable to advocate for themselves.


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EDUCATED NURSES Establishes and maintain respect, empathy, trust and integrity in interactions with clients.

Where, when and how I demonstrated this skill: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________

Establishes and maintains a caring environment that supports clients in achieving optimal health outcomes, goals to manage illness or a peaceful death.


Document and maintain clear, concise, accurate and timely records using both paper-based and electronic methods, in accordance with nursing standards and the practice setting’s policies.


Maintains clear, concise, accurate and timely records of clients’ care.

Where, when and how I demonstrated this skill: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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EDUCATED NURSES Adhere to legal requirements regarding documentation: complete occurrence reports as required.

Where, when and how I demonstrated this skill: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________

Practise according to relevant mandatory reporting legislation and other reporting requirements under legislation, regulation, by-laws and policies applicable to licensed practical nurses.

Where, when and how I demonstrated this skill: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________

Initiate contact and receive, transcribe and verify orders.


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EDUCATED NURSES Recognize, respond and appropriately report questionable orders, actions or decisions made by other healthcare workers.


Based on ethical and legal considerations, maintains client confidentiality in all forms of communication.


Effectively communicates appropriate information about clients’ care with the inter-professional healthcare team while respecting confidentiality.


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EDUCATED NURSES Recognize and respond to the clients’ right to healthcare information.

Where, when and how I demonstrated this skill: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Knowledge about personal health information legislation and privacy legislation.

Where, when and how I demonstrated this skill: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


PAYMENT INFORMATION (please print)

Date: Amount: $340.00

Payment Description: Application Fee

PERSONAL INFORMATION (please print)

Name:

Address:

City: Province: Postal Code:

Phone: Fax:

Email:

INTERNATIONALLY EDUCATED – APPLICATION FEE CREDIT CARD AUTHORIZATION FORM

For privacy and security reasons, once payment is processed the below section will be destroyed.

CREDIT CARD INFORMATION (please print)

Cardholder Name:

Credit Card #:

Expiry Date: Month: Year: Credit Card: VISA MasterCard

Signature: Date:

Documents

INTERNATIONALLY EDUCATED APPLICATION FOR REGISTRATION … · INTERNATIONALLY EDUCATED NURSES APPLICATION ... if you have any outstanding questions send ... application for registration