2018 Reinstatement Application Package

Transcription

1 PREVIOUSLY REGISTERED WITH CLPNA 2018 Reinstatement Application Package Thank you for your recent request for information on reinstatement of your Alberta Practical Nurse registration in Alberta. Below is a brief description of what is necessary to begin this process. Please read through carefully. MANDATORY FORMS TO RETURN DIRECTLY TO CLPNA Reinstatement of Practical Nurse Application Form The CLPNA policy has established that you must be actively engaged in practice within the previous 4 years to qualify for registration as a practical nurse. Meeting this requirement is done through a declaration of the hours you have worked within the previous 4 years. Applicants with zero practice hours in the previous four years will be asked to complete a practical nurse Refresher program. CLPNA reserves the authority to request verification of the hours that have been declared on this reinstatement form. 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: Criminal Record Checks are considered valid for 6 months from the date of issue. Declaration of Reinstatement of Practical Nurse and Employer Validation (For LPNs Practicing in Alberta) This form must be completed as a requirement of reinstatement. You are required to complete Section 1-3 of the Declaration form. Learning Objectives If you held a practice permit at any time in 2017 please identify the learning objective, resources & strategies and plan implemented for the learning plan you identified for your 2017 renewal or declare alternate learning that you did complete for If you did not hold a permit in 2017 you can leave this section blank. All applicants are required to identify a learning plan for ADDITIONAL FORMS TO FORWARD APPROPRIATELY (NOT APPLICABLE TO EVERY APPLICANT) Verification of Registration Form If you were registered in another jurisdiction while your Alberta registration was inactive, forward this form to the regulatory organization in all other jurisdictions in which you held a registration. The form will be returned directly to our office. Jurisprudence Exam (Last Registration with CLPNA prior to 2014) If your application is received after January 1, 2018 you will be required to complete the Jurisprudence Exam IF your last registration with CLPNA was prior to REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 1 of 14

2 FEE SCHEDULE 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: Visa, MasterCard (fill out form attached), Money Order, Certified Cheque, Cash or Debit (in CLPNA Office). Practice Permits expire annually on December 31. Fee Schedule After January 1, 2018 For Reinstatements issued between January 2, 2018 and July 31, 2018 Application Fee $60 Practice Permit Fee $350 Total $410 For Reinstatements issued between August 1, 2018 and December 31, 2018 Application Fee $60 Practice Permit Fee $175 Total $235 The CLPNA will not issue a Practice Permit more than 3 months in advance of the Effective Date of the Permit. REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 2 of 14

3 REINSTATEMENT OF LICENSED PRACTICAL NURSE REGISTRATION 2018 Reinstatement Application Package PERSONAL (Please Print) Current Legal Surname (Last Name) Maiden Name _ Given Name (First Name) _ Date of Birth (dd/mm/yy) Middle Name(s) Sex Female Male Apartment / Box No. / Address or Street No. City / Town / Village Province/State Telephone No. _ Country _ Cell No. Postal Code / Zip Code Primary Language Address (Mandatory) CLPNA Registration Number NURSING EMPLOYMENT HISTORY (Please Print: Provide all employers in the past 4 years. More than 2 please provide on a separate piece of paper.) Employer Name and Phone Address Unit/Area of Responsibility (check applicable boxes) Job Title/Position Start Date (dd/mm/yy) Status (Full-Time, Part-Time, Casual) End date (dd/mm/yy) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term Care Pediatrics Other NURSING EMPLOYMENT HISTORY CON T (Please Print: Provide all employers in the past 4 years. More than 2 please provide on a separate piece of paper.) Employer Name and Phone Address Unit/Area of Responsibility (check applicable boxes) Job Title/Position Start Date (dd/mm/yy) Status (Full-Time, Part-Time, Casual) End date (dd/mm/yy) Medical Mental Health/Psychiatry Surgical Community Obstetrics Gerontology/Long Term Care Pediatrics Other REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 3 of 14

4 DID YOU COMPLETE YOUR CLPNA LEARNING PLAN OBJECTIVES FOR 2017? I did not hold a practice permit in 2017 (go to Learning Plan for 2018) If you held an Active status in 2017 you are required to report on a MINIMUM of TWO (2) completed Learning Objectives for For each Learning Objective listed below: To identify the learning you selected at renewal for 2017 check your online profile at To select alternate learning please use the Appendix at the back of the document If you completed or partially completed the objective, check off YES or PARTIAL in the Plan Implemented column. Learning Objective What Learning Objective did you complete or plan to complete in 2017? Resources & Strategies How did you meet or plan to meet the Learning Objective in 2017? Plan Implemented? Did you complete or plan to complete the Learning Objectives in 2017? If NO, check ONE reason below Then enter Alternate learning and resource codes in the boxes provided. #1 Learning Objective: Enter Code from Appendix A, Section 1 #2 Learning Objective: Enter Code from Appendix A, Section 1 Resources & Strategies: Enter Code from Appendix A, Section 2 Resources & Strategies: Enter Code from Appendix A, Section 2 Yes Partial No Check ONE reason in next column Yes Partial No Check ONE reason in next column Chose too many Learning Objectives Completed alternate learning Did not work as LPN Education not available Leave of absence Chose too many Learning Objectives Completed alternate learning Did not work as LPN Education not available Leave of absence CONTINUING COMPETENCY LEARNING PLAN FOR 2018 #1 Learning Objectives What are you going to learn? Your Learning Plan is an outline of how you will meet your Continuing Competency learning objectives for You are required to enter all information for a MINIMUM of TWO (2) Learning Plan Objectives you plan to complete in The Continuing Competency Program (CCP) Self-Assessment Tool can help you with your Learning Plan. Follow this link to the Continuing Competency Program. It is MANDATORY to enter two (2) Learning Objectives. Use Codes from Appendix A. Resources & Strategies Target Date Evaluation What will you do to meet the Learning What is your time frame for completion? How will you know you learned the Objective? Learning Objective? #2 Enter Code from Appendix A, Section 1 Enter Code from Appendix A, Section 2 Enter Code from Appendix A, Section 3 Enter Code from Appendix A, Section 4 Enter Code from Appendix A, Section 1 Enter Code from Appendix A, Section 2 Enter Code from Appendix A, Section 3 Enter Code from Appendix A, Section 4 REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 4 of 14

5 GOOD STANDING DECLARATION OTHER PROFESSIONAL REGISTRATIONS Other than with CLPNA, list all current registrations/licenses in practical nursing or other professions (ie. registered nurse, physiotherapist, midwife, paramedic, etc.) and check to declare whether or not you are in good standing with the other regulatory organization(s). If you have more than one, write in the regulated profession in the space provided in question 12. If you are not currently registered in another jurisdiction list the last jurisdiction in which you held registration and provide verification from that jurisdiction. Registration Type (LPN, RN) Registration Status Conditions/Limitations on Registration (if applicable) Province/State/ Country Registration Number Issued Date (dd/mm/yy) Expiry Date (dd/mm/yy) I DECLARE that the active license(s) I possess to practice in other jurisdictions are in good standing. Yes, I am in good standing No, I am NOT in good standing PERSONAL DECLARATION (check applicable answer) For more information on the CLPNA s authority to request an applying member to self-declare, visit 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. If any circumstances change throughout the year, you are required to contact CLPNA. Character and Reputation: Since you last applied for registration with CLPNA: 1. Are you currently under investigation or been the subject of proceeding of any kind by a regulatory or legislative body in Alberta, any other province, territory, or country (excluding CLPNA)? 2. Have you been disciplined by a regulatory body in Alberta, any other province, territory, or country (excluding CLPNA)? 3. Are you currently charged with any criminal offense? 4. Have you plead guilty or been found guilty of a criminal offense for which a pardon has not been granted? If you answered YES to question 4, submission of a current criminal record check is required to review your application for reinstatement. 1. Yes 2. Yes 3. Yes 4. Yes No No No No Fitness to practice: Since you last applied for registration with CLPNA: 5. Do you have any physical OR mental condition OR disorder that may impair your ability to provide safe, competent and ethical care? 5.1 If yes, are you under the care of a physician or healthcare team? 5.2 If yes, are you following medical advice? 5. Yes 5.1 Yes 5.2 Yes No No No IMPORTANT: If you answered YES to any of the questions above, provide a brief narrative. You may be required to provide further documentation. The information contained on this application form is true and correct to the best of my knowledge and make this declaration for the purpose of inducing the CLPNA to issue me an active practice permit. I am of good character and fit to practice, consistent with the responsibilities, ethics and standards expected of an LPN. I understand that falsification of information provided on this application form is considered unprofessional conduct as per the Health Professions Act. Signature: Date: REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 5 of 14

6 REINSTATEMENT OF LICENSED PRACTICAL NURSE REGISTRATION Declaration of Employment Information If you have more than one position please complete additional forms. Section 1 LPN Employment Information (Alberta Employers ONLY) EMPLOYMENT INFORMATION Complete for Each LPN Employer (Mandatory): Do you currently hold a position as an LPN in Alberta? Yes No Facility Name: Supervisor Name: Supervisor Phone: Supervisor Date of Last Shift Worked: Date of Next Scheduled Shift: Section 2 Other Employment Information OTHER EMPLOYMENT INFORMATION Complete for Each LPN Employer (Mandatory): Do you currently hold a position in another health care role (ie. Medical Office Assistant, Health Care Aide)? Yes No Position Title: Facility Name: Supervisor Name: Supervisor Phone: Supervisor Date of Last Shift Worked: Next Scheduled Shift Section 3 Declaration of Licensed Practical Nurse PLEASE CHECK ONE APPLICABLE BOX: (Mandatory) I attest that I have not and will not practice (this includes orientation, buddy shifts, or doing any training required in the role as an LPN) as a LPN in Alberta in 2018 without a 2018 practice permit. I attest that I have practiced as a LPN (this includes orientation, buddy shifts, or doing any training required in the role as an LPN) in Alberta in 2018 without a valid 2018 practice permit. - Please write date(s) worked below, and supervisor s contact information. - Attesting to having practiced without a practice permit will result in a review by the CLPNA Complaints Director. - Employers will be contacted to verify this information. REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 6 of 14

7 Section 3 (continued) Declaration of Licensed Practical Nurse I have not maintained an Active Practice Permit with the CLPNA and I am requesting reinstatement of my LPN practice permit. Any of the information submitted in the above declaration is subject to verification by the CLPNA in accordance with the Health Professions Act (HPA), Licensed Practical Nurses Profession Regulation, CLPNA Bylaws and CLPNA policies. Working in certain positions within the health care sector and not holding a valid practice permit may be subject to review under Section 46(1) of the HPA. Additionally, it is considered an offence under the HPA to practice as an LPN without a valid practice permit in a position designated as an LPN position or to use the protected title as an LPN while not registered with the CLPNA. Contravention of the HPA may result in charges of unprofessional conduct and sanctions, including a fine. I have understood my responsibilities as a regulated member of the CLPNA and if I did have any questions or concerns they were addressed prior to signing this Declaration of Reinstatement as a Licensed Practical Nurse. SIGNATURE OF DECLARATION (Mandatory): LPN Name: LPN Signature: Dated this (day) of (month) (year) Section 4 Office Use Only Verification Required: YES NO Employer Contacted(1 st Attempt): Date: By: Employer Contacted(2 nd Attempt): Date: By: Information Confirmation Date: By: Referred to Conduct Department: YES NO Date: Action Taken: Notes: REINSTATEMENT APPLICATION FOR 2018 Revised March 14, 2018 Page 7 of 14

8 REINSTATEMENT OF LICENSED PRACTICAL NURSE REGISTRATION DECLARATION OF EMPLOYMENT HOURS Complete Section 1 for all employers in the past 4 years. If you have more than 2 employers please print additional forms. SECTION 1 (completed by applicant) PERSONAL (Please Print) Current Legal Surname (Last Name) Maiden Name _ Given Name (First Name) _ Date of Birth (dd/mm/yy) Middle Name(s) Sex Female Male Apartment / Box No. / Address or Street No. City / Town / Village Province/State Telephone No. _ Country _ Cell No. Postal Code / Zip Code Primary Language Address EMPLOYMENT DETAILS (Please Print) Facility Name Start Date (dd/mm/yy) End Date (dd/mm/yy) Job Title/Position Supervisor Name EMPLOYMENT HOURS Year Employed Supervisor Job Title/Position Total Hours Worked Unit/Area of Responsibility (check applicable boxes) Medical Mental Health/Psychiatry Surgical Community Obstetrics Pediatrics Gerontology/Long Term Care Other REINSTATEMENT DECLARATION OF EMPLOYMENT HOURS FORM Revised December 19, 2017 Page 8 of 14

9 EMPLOYMENT DETAILS (Please Print) Facility Name Start Date (dd/mm/yy) End Date (dd/mm/yy) Job Title/Position Supervisor Name EMPLOYMENT HOURS Year Employed Supervisor Job Title/Position Total Hours Worked Unit/Area of Responsibility (check applicable boxes) Medical Mental Health/Psychiatry Surgical Community Obstetrics Pediatrics Gerontology/Long Term Care Other SECTION 2 - Declaration The information contained on this Declaration of Employment Hours form is true and correct to the best of my knowledge. I make this declaration for the purpose of inducing the CLPNA to issue me an active practice permit. I understand that CLPNA may request verification from my previous or current employers at their discretion. I understand that falsification of information provided on this application form is considered unprofessional conduct as per the Health Professions Act. Signature: Date: REINSTATEMENT DECLARATION OF EMPLOYMENT HOURS FORM Revised December 19, 2017 Page 9 of 14

10 VERIFICATION OF REGISTRATION Complete Section 1 and forward to the appropriate registration/nursing board(s) to complete Section 2. Once completed, the form must be mailed or ed directly from the registration/nursing board(s) to CLPNA. Copies will not be accepted. SECTION 1 (completed by applicant) PERSONAL (Please Print) Current Legal Surname (Last Name) Maiden Name _ Given Name (First Name) _ Date of Birth (dd/mm/yy) Middle Name(s) Sex Female Male Apartment / Box No. / Address or Street No. City / Town / Village Province/State Telephone No. _ Country _ Cell No. Postal Code / Zip Code Primary Language Address EDUCATION (Please Print) _ Name of Nursing Program _ Name of Educational Institution Graduation Date (dd/mm/yy) Educational Institution Complete Address REGISTRATION (Please Print) Name of Registration/Nursing Board Initial Registration Date with Board (dd/mm/yy) Registration Number CONSENT TO RELEASE INFORMATION I am seeking registration as a Licensed Practical Nurse in Alberta. I authorize (name of Registration/Nursing board) to complete Section 2 of this form and mail the required documentation directly to the College of Licensed Practical Nurses of Alberta (CLPNA). Applicant Signature (do not print) Date (dd/mm/yy) REINSTATEMENT VERIFICATION OF REGISTRATION Revised December 19, 2017 Page 10 of 14

11 SECTION 2 (completed by registration/nursing board) THIS CERTIFIES THAT (Please Print) Current Legal Surname (Last Name) _ Given Name (First Name) Middle Name(s) Nursing School/Educational Program Educational Facility Address Completion Date (dd/mm/yy) Registered by Examination Endorsement _ Initial Registration Date (dd/mm/yy) _ Name of Examination Written _ Expiry Date (dd/mm/yy) _ Date Examination Written (dd/mm/yy) Registration Number Language of Examination Number of Times Examination was Written Results Pass Fail Current Status Registered Inactive FORMAL ACTIONS 1. Has the applicant s registration ever been revoked, suspended, or under review? Yes No 2. Has the applicant s registration ever been made subject to conditions, limitations, restrictions, and/or an agreement with the board? 3. Has the applicant ever voluntarily surrendered their registration with the board and/or any other jurisdiction? Yes Yes No No 4. Has the applicant ever been denied registration? Yes No 5. Is there now or has there ever been any formal disciplinary action commenced against the applicant? Yes No 6. Have there ever been any formal sanctions imposed against the applicant as a matter of public record? (If yes, attach a certified copy of disciplinary action.) Yes No 7. Is the applicant the subject of a current investigation, proceeding, outstanding, and/or unresolved complaint against them in relation to their practice of nursing? Yes If Yes is the answer to any of the questions, please attach documentation outlining action(s) taken. No ACTING ON BEHALF OF REGISTRATION, BOARD, OR COUNCIL _ Signature of Registrar/Designate Title Print Name Place Official Stamp or Seal Here _ Name of Licensing Authority/Jurisdiction Date (dd/mm/yy) REINSTATEMENT VERIFICATION OF REGISTRATION Revised December 19, 2017 Page 11 of 14

12 2018 REINSTATEMENT CREDIT CARD AUTHORIZATION FORM PAYMENT INFORMATION (please print) Date: Payment Description: Amount: REINSTATEMENT APPLICATION FEE Check the Appropriate Box $60.00 Application Fee PERSONAL INFORMATION (please print) Name: Address: City: Province: Postal Code: Phone: Fax: 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: REINSTATEMENT APPLICATION FOR 2018 Revised December 19, 2017 Page 12 of 14

13 APPENDIX A Continuing Competency Program Learning Plan Coding Guide SECTION 1 LEARNING OBJECTIVES Choose a minimum of TWO (2) Learning Objectives using the Competency Codes below for Sections 9 & 10. (Codes are from the Competency Profile for LPNs, 3rd Ed., available at A: Nursing Knowledge A1: Anatomy and Physiology A2: Microbiology A3: Pathophysiology A4: Medical Terminology A5: Growth and Development A6: Nutrition A7: Pharmacology A8: Social Science and Humanities A9: Best Practices and Research B: Nursing Process B1: Assessment B2: Nursing Diagnosis B3: Planning B4: Implementation B5: Evaluation C: Safety C1: Urgent and Emergent Situations C2: Protective Equipment C3: Infection Prevention and Control C4: Client Safety C5: Workplace Safety D: Communication & Interpersonal Skills D1: Effective Communication D2: Collaborative Team Practice D3: Therapeutic Nurse-Client Relationship D4: Health Teaching and Coaching D5: Legal Protocols, Documenting and Reporting D6: Accept, Transcribe and Initiate Orders D7: Conflict Management E: Nursing Practice E1: Critical Thinking and Critical Inquiry E2: Clinical Judgment and Decision Making E3: Time Management E4: Admission and Discharge E5: Activities of Daily Living E6: Nutrition/Hydration E7: Elimination E8: Peritoneal Dialysis E9: Basic Foot Care E10: Basic Wound Care E11: Advanced Wound Care E12 Phlebotomy E13: Client Centered Care E14: Complementary and Alternative Therapies E15: Ear Syringing E16: Post Mortem Care F: Respiratory Care F1: Airway Management F2: Oxygen Therapy F3: Suctioning F4: Respiratory Interventions F5: Tracheostomy Care F6: Chest Tubes G: Surgical G1: Surgical Nursing G2: Surgical Nursing Interventions G3: Endoscopy G4: Post Anesthetic Recovery H: Orthopedics H1: Orthopedic Nursing H2: Orthopedic Nursing Interventions H3: Traction and Immobilizers I: Neurological/Neurosurgical I1: Neurological Nursing I2: Neurological Nursing Interventions I3: Managing C-Spine I4: Advanced Neurological Nursing Interventions J: Cardiovascular J1: Cardiovascular Nursing J2: Cardiovascular Interventions J3: Advanced Cardiovascular Interventions K: Maternal/Newborn Care K1: Maternal/Newborn Nursing K2: Prenatal Care K3: Knowledge and Assessment of Labor K4: Assist with Managing Labor K5: Assist with Delivery K6: Neonatal Resuscitation K7: Labor and Delivery of Non-Viable Fetus K8: Post-Partum Care K9: Newborn Care K10: Care of Critically Ill or Premature Newborn L: Pediatrics L1: Pediatric Nursing L2: Pediatric Care and Interventions L3: Pediatric Pain Management M: Mental Health and Addiction M1: Mental Health and Addiction Nursing M2: Mental Health and Addiction Assessment and Intervention M3: Aggressive Behavior N: Emergency Care N1: Emergency Nursing N2: Triage O: Gerontology O1: Gerontology Nursing O2: Gerontology Care and Interventions O3: Cognitive Care O4: Dementia Care O5: Assessment and Planning in Continuing Care P: Palliative Care P1: Palliative Principles and Values P2: Physical Changes P3: Physical and Psychosocial Care P4: Post Mortem Care Q: Rehabilitation Q1: Rehabilitation Nursing R: Community Health R1: Community Health Nursing R2: Nursing Process and Community Health R3: Health Promotion R4: Client Services R5: Community Health Teaching and Coaching R6: Public Health Nursing R7: Clinic Nursing R8: Case Management S: Oncology S1: Oncology Nursing S2: Oncology Interventions T: Occupation Health and Safety T1: Occupational Health and Safety Nursing U: Medication Administration U1: Principles of Pharmacology U2: Medication Preparation and Administration U3: Nitrous Oxide V: Infusion Therapy V1: Principles of Infusion Therapy V2: Peripheral Intravenous Therapy V3: Hypodermoclysis (HDC) V4: Central Line Care V5: Blood and Blood Products V6: Epidural and Spinal Infusions V7: Total Parenteral Nutrition W: Professionalism W1: Legislation and Regulation W2: Licensed Practical Nurse Scope of Practice W3: Professional Standards of Practice W4: Professional Ethics W5: Accountability and Responsibility W6: Professional Boundaries W7: Fitness to Practice W8: Professional Development X: Leadership X1: Informal Leadership X2: Formal Leadership X3: Manager/Administrator Y: Orthopedic Specialty Y1: Self-Regulation and Accountability Y2: Specialized Orthopedic Knowledge and Application Y3: Treatments and Interventions Z: Perioperative Specialty Z1: Self-Regulation and Accountability Z2: Specialized Perioperative Knowledge Z3: Pre-Operative Role Z4: Perioperative Circulating Role Z5: Assist Anesthesia Provider Z6: Perioperative Scrub Role Z7: Post Anesthetic Recovery Role AA: Dialysis Specialty AA1: Self-Regulation and Accountability AA2: Specialized Hemodialysis Knowledge BB: Independent Practice BB1: Self-Regulation and Accountability BB2: Independent Practice Services CC: Advanced Foot Care CC1: Self-Regulation and Accountability CC2: Advanced Foot Care Practice DD: Dermatology DD1: Dermatology Nursing DD2: Dermatology Interventions EE: Educator EE1: Adult Learning Principles EE2: Design and Delivery of Education FF: Ophthalmology FF1: Ophthalmic Nursing FF2: Ophthalmic Interventions GG: Immunization Specialty GG1: Self-Regulation and Accountability GG2: Immunity and Communicable Disease Control GG3: Principles of Immunizing/Biological Agents GG4: Assessment of Client Prior to Immunization GG5: Informed Consent and Client Teaching GG6: Prepare Immunizing/Biological Agents GG7: Administer Immunizing/Biological Agents U4: Contrast Agents REINSTATEMENT APPLICATION FOR 2018 Revised December 19, 2017 Page 13 of 14

14 SECTION 2 RESOURCES & STRATEGIES What will you do to meet your Learning Objective? 01 CLPNA Website 02 Conference/Workshop 03 College/University Education 04 Employer certification education 05 Employer in-service 06 Teaching/Preceptoring 07 Internet Research 08 Journals/Books 09 Committee Involvement SECTION 3 TARGET DATE What is your time frame for completion? months months months months 05 Ongoing SECTION 4 EVALUATION How will you know your learned the Learning Objective? 01 Developed program/process/product 02 Enhanced accountability 03 Enhanced critical thinking/decision-making 04 Improved communication skills 05 Improved work environment 06 Increased confidence 07 Increased knowledge/skill/competence REINSTATEMENT APPLICATION FOR 2018 Revised December 19, 2017 Page 14 of 14