Sample Application Volunteer Letter

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					                                  RENEWAL BY
                               SYNERGY CERPs LOG

          3-Year Renewal Period:
                                                    From                        To


Instructions for use:
1. Save this template to your computer, noting the file name and where it is saved.
2. Open the newly saved file in MS Excel.
3. Type in your 3-year certification renewal period on pages 1 and 2.
4. Type in your CE courses and CERPs as you complete them; CERP totals calculate for you in each category.
5. If audited, print pages 2-4, sign, date and submit with CERP documentation, RN license copy & verification letter.

Click on tab 2 (below) to view a sample of a completed Synergy CERP Log.

For questions about which category to log your course or CE activity, refer to these links:
www.certcorp.org
Documents and Handbooks
Renewal by Synergy CERPs At-a-Glance
Renewal Handbook
Synergy CERPs Online CE Resources
   Or call (800) 899-2226 to speak with AACN Customer Care.


Reminders:
1 contact hour or 1 CE is equal to 1 CERP.
Minimum CERPs are: Category A - 60, Category B - 10, Category C -10, plus 20 in the category of your choice.
For Academic Credit Courses, 1 credit is worth 15 CERPs. For example, a 3-credit course is worth 45 CERPs.



                                          AACN Certification Corporation
                                        101 Columbia, Aliso Viejo, CA 92656
                                                  (800) 899-2226
                                                Fax (949) 362-2020
                                                 www.certcorp.org




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                                        Renewal by SYNERGY CERPs LOG
                                                     (Categories A, B and C)
                                                Do NOT Submit Unless Being Audited!

Name:                                                                               AACN Customer #:

                          3-Year Renewal Period:
                                                              From                         To


Candidates seeking CCRN or PCCN certification renewal status must accumulate 100 CERPs (Continuing Education
Recognition Points) in specific categories within the 3-year period prior to the scheduled certification renewal date in order to
maintain active certification status.
                                                            DIRECTIONS
Type in your information in the shaded area.
If you are selected for an audit, attach copies of all documents verifying continuing education activities, in the order listed, to this
form. Do not submit originals. Submit to: AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656-4109.


Category A: Clinical Judgment and Clinical Inquiry
60 CERPs Minimum / 80 CERPs Maximum
Ongoing learning topics include all CE, academic, e-learning, CME courses and/or in-services related to a clinical judgment or
clinical inquiry topic on the test plan. Topics must have direct application to the needs of the acutely and/or critically ill patient/
family. Activities may include taking a certification review course (e.g., CCRN, PCCN, CMC, CSC); completing the CCRN or
PCCN SAE; publishing; performing audits; QA/QI activities; performing committee work related to clinical inquiry or clinical
judgment. Examples: lab values, BLS, ACLS, PALS, NRP, ECG, IV therapy, heart failure, pharmacology, assessment,
pathophysiology, technical skills/new equipment, statistics, clinical research, evidence-based practice, auditing, publishing,
practice protocols and clinical aspects of bioterrorism.

                                                                               No. of hours in course
           Ongoing Learning Topic                        Sponsoring                                                     CERPs Office
                                                                                or Academic Course         Date(s)
            (Title of Program or Activity)               Organization                                                  Awarded Use
                                                                                       credits
   1
   2
   3
   4
   5
   6
   7
   8
   9
  10
  11
  12
  13
  14
  15
  16
  17
  18
                                                                                                  Category A total:       0.00




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Category B: Advocacy/Moral Agency, Caring Practices, Response to Diversity, and Facilitation of
Learning
10 CERPs Minimum / 30 CERPs Maximum
Ongoing learning topics may be in-service, CEs, or academic courses that address subjects that have direct application to the
needs of the acutely and/or critically ill patient/family. Activities may be related to infection control; patient safety; conducting
professional presentations; or developing teaching aids. Activities may also include volunteer work that has a clinical judgment
component. The volunteer activity should be performed outside the nurse’s salaried position. CERPs are granted based on the
individual activity, not the total number of hours spent on the activity. Examples: legal or ethical issues, charting/documentation,
reducing medication errors, public policy, HIPAA, Joint Commission, end-of-life care, advance directives, comfort/pain control,
stress management, patient support groups, geriatric care, diversity, cultural aspects of care, medical Spanish, therapeutic
communication, psychosocial aspects of care, spiritual considerations, precepting/mentoring, teaching in-services/programs,
developing patient education tools and the value of certification.

                                                                            No. of hours in course
          Ongoing Learning Topic                       Sponsoring                                                   CERPs Office
                                                                             or Academic Course         Date(s)
           (Title of Program or Activity)              Organization                                                Awarded Use
                                                                                    credits
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10

                                                                            Number Contact Hours                    CERPs Office
                       Presentation/Program Title                                                Date(s)
                                                                                  Taught                           Awarded Use
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10

                                                                               Number of Hours                      CERPs Office
                     Activity                          Organization                                     Date(s)
                                                                              Involved in Activity                 Awarded Use
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10
                                                                                               Category B total:      0.00




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Category C: Collaboration and Systems Thinking
10 CERPs Minimum / 30 CERPs Maximum
Ongoing learning topics include all CE, academic, e-learning, CME courses and/or in-services that address subjects that have
direct application to the needs of the acutely and/or critically ill patient/family. Activities may include AACN or other national
organization committee work; leadership roles on committees; or membership in a professional organization (e.g., ANA, AACN).
Current membership in a professional healthcare organization is limited to two (2) organizations at 3 CERPs per year each, for up
to 18 CERPs per renewal period. Examples: communication skills, teamwork, healthy work environments, Synergy Model for
Patient Care, redesigning hospital care, disaster/emergency planning, developing policies or procedures, leadership,
management, risk management, community resources and case management.


                                                                            No. of hours in course
           Ongoing Learning Topic                         Sponsoring                                               CERPs Office
                                                                             or Academic Course        Date(s)
            (Title of Program or Activity)                Organization                                            Awarded Use
                                                                                    credits
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10

                                                                                                                   CERPs Office
      Committee Work / Leadership Roles                              Organization                      Date(s)
                                                                                                                  Awarded Use
  1
  2
  3
  4
  5
  6
  7
  8
  9
 10

          Professional Membership                                                                                  CERPs Office
                                                       Membership Number            Membership Period
              (Name of Organization)                                                                              Awarded Use
  1
  2
  3
  4
  5
                                                                                              Category C total:    0.00
                        Category             Min/Max    Number of CERPs
                           A                  60-80          0.00
                           B                  10-30          0.00
                           C                  10-30          0.00
                         Grand Total (>100):                 0.00

By signing below I affirm that the information listed on this CERP Log is true and correct.

  Signature: ___________________________________                                    Date: ________________

         1591e7c8-9a02-4f67-806e-d1e70775e4a4.xls                4 of 8                                           7/28/2011
                                  RENEWAL BY
                               SYNERGY CERPs LOG
                                             (SAMPLE)
          3-Year Renewal Period:             October 1, 2006         September 30, 2009
                                                    From                         To



Instructions for use:
1. Save this template to your computer, noting the file name and where it is saved
2. Open the newly saved file in MS Excel.
3. Type in your 3-year certification renewal period on pages 1 and 2.
4. Type in your CE courses and CERPs as you complete them; CERP totals calculate for you in each category.
5. If audited, print pages 2-4, sign, date and submit with CERP documentation, RN license copy & verification letter.

For questions about which category to log your course or CE activity, refer to these links:
www.certcorp.org
Documents and Handbooks
Renewal by Synergy CERPs At-a-Glance
Renewal Handbook
Synergy CERPs Online CE Resources
   Or call (800) 899-2226 to speak with AACN Customer Care.


Reminders:
1 contact hour or 1 CE is equal to 1 CERP.
Minimum CERPs are: Category A - 60, Category B - 10, Category C -10, plus 20 in the category of your choice.
For Academic Credit Courses, 1 credit is worth 15 CERPs. For example, a 3-credit course is worth 45 CERPs.



                                          AACN Certification Corporation
                                        101 Columbia, Aliso Viejo, CA 92656
                                                  (800) 899-2226
                                                Fax (949) 362-2020
                                                 www.certcorp.org




1591e7c8-9a02-4f67-806e-d1e70775e4a4.xls                5 of 8                                            7/28/2011
                                        Renewal by SYNERGY CERPs LOG
                                                     (Categories A, B and C)
                                                Do NOT Submit Unless Being Audited!

Name:                                 Mary Smith                                      AACN Customer #:                  123456

                          3-Year Renewal Period:      October 1, 2006           September 30, 2009
                                                              From                          To


Candidates seeking CCRN or PCCN certification renewal status must accumulate 100 CERPs (Continuing Education Recognition
Points) within the 3-year period prior to the certification expiration date in order to maintain active certification status.

                                                            DIRECTIONS
Type in your information in the shaded area.
If you are selected for an audit, attach copies of all documents verifying continuing education activities, in the order listed, to this
form. Do not submit originals. Submit to: AACN Certification Corporation, 101 Columbia, Aliso Viejo, CA 92656-4109.

Category A: Clinical Judgment and Clinical Inquiry
60 CERPs Minimum / 80 CERPs Maximum
Ongoing learning topics include all CE, academic, e-learning, CME courses and/or in-services related to a clinical judgment or
clinical inquiry topic on the test plan. Topics must have direct application to the needs of the acutely and/or critically ill patient/
family. Activities may include taking a certification review course (e.g., CCRN, PCCN, CMC, CSC); completing the CCRN or
PCCN SAE; publishing; performing audits; QA/QI activities; performing committee work related to clinical inquiry or clinical
judgment. Examples: lab values, BLS, ACLS, PALS, NRP, ECG, IV therapy, heart failure, pharmacology, assessment,
pathophysiology, technical skills/new equipment, statistics, clinical research, evidence-based practice, auditing, publishing,
practice protocols and clinical aspects of bioterrorism.

                                                                                No. of hours in course
           Ongoing Learning Topic                        Sponsoring                                                      CERPs Office
                                                                                 or Academic Course          Date(s)
            (Title of Program or Activity)               Organization                                                   Awarded Use
                                                                                        credits
  1                  ACLS Renewal                   American Heart Assoc.                    8                10/6/06      8.00
  2                     IV Therapy                 Memorial Medical Center                   4               10/15/06      4.00
  3              ECG Interpretation                Memorial Medical Center                  3                11/12/06      3.00
  4         Wrote standard of care for VAP         Memorial Medical Center                 N/A                4/15/08      3.00
   5            QI coordinator on unit             Memorial Medical Center                 N/A              2008-2009      6.00
   6       Evidence-Based Practice (EBP)           Memorial Medical Center                  3                8/30/08       3.00
   7         Cardiac Medication Update             Memorial Medical Center                  4                 8/5/09       4.00
   8          Respiratory Emergencies              Memorial Medical Center                  8                9/15/09       8.00
   9         Health Assessment course               Kent State University                   3               1/09-5/09     45.00
  10
  11
  12
  13
  14
  15
  16
  17
  18
                                                                                                    Category A total:     84.00




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Category B: Advocacy/Moral Agency, Caring Practices, Response to Diversity, and Facilitation of
Learning
10 CERPs Minimum / 30 CERPs Maximum
Ongoing learning topics may be in-service, CEs, or academic courses that address subjects that have direct application to the
needs of the acutely and/or critically ill patient/family. Activities may be related to infection control; patient safety; conducting
professional presentations; or developing teaching aids. Activities may also include volunteer work that has a clinical judgment
component. The volunteer activity should be performed outside the nurse’s salaried position. CERPs are granted based on the
individual activity, not the total number of hours spent on the activity. Examples: legal or ethical issues, charting/documentation,
reducing medication errors, public policy, HIPAA, Joint Commission, end-of-life care, advance directives, comfort/pain control,
stress management, patient support groups, geriatric care, diversity, cultural aspects of care, medical Spanish, therapeutic
communication, psychosocial aspects of care, spiritual considerations, precepting/mentoring, teaching in-services/programs,
developing patient education tools and the value of certification.

                                                                              No. of hours in course
          Ongoing Learning Topic                       Sponsoring                                              CERPs Office
                                                                               or Academic Course     Date(s)
           (Title of Program or Activity)              Organization                                           Awarded Use
                                                                                      credits
  1          Precepting new staff nurses           Memorial Med. Center                 N/A          2006-2009 18.00
  2
  3
  4
  5
  6
  7
  8
  9
 10

                                                                             Number Contact Hours                     CERPs Office
                        Presentation/Program Title                                                        Date(s)
                                                                                   Taught                            Awarded Use
  1                Gave inservice on COPD to staff nurses                            1.5                  8/15/08      4.50
  2            Gave inservice on Infection Control to staff nurses                    2                   9/25/08      6.00
  3
  4
  5

                                                                                Number of Hours                       CERPs Office
                     Activity                          Organization                                       Date(s)
                                                                               Involved in Activity                  Awarded Use
  1       Health Fair - BP & glucose checks              Red Cross                      3                 4/11/08      3.00
  2
  3
  4
  5
  6
  7
  8
  9
 10
                                                                                                 Category B total:     31.50




        1591e7c8-9a02-4f67-806e-d1e70775e4a4.xls                7 of 8                                               7/28/2011
Category C: Collaboration and Systems Thinking
10 CERPs Minimum / 30 CERPs Maximum
Ongoing learning topics may be in-service, CEs, or academic courses that address subjects that have direct application to the
needs of the acutely and/or critically ill patient/family. Activities may be related to infection control; patient safety; conducting
professional presentations; or developing teaching aids. Activities may also include volunteer work that has a clinical judgment
component. The volunteer activity should be performed outside the nurse’s salaried position. CERPs are granted based on the
individual activity, not the total number of hours spent on the activity. Examples: legal or ethical issues, charting/documentation,
reducing medication errors, public policy, HIPAA, Joint Commission, end-of-life care, advance directives, comfort/pain control,
stress management, patient support groups, geriatric care, diversity, cultural aspects of care, medical Spanish, therapeutic
communication, psychosocial aspects of care, spiritual considerations, precepting/mentoring, teaching in-services/programs,
developing patient education tools and the value of certification.

                                                                              No. of hours in course
           Ongoing Learning Topic                         Sponsoring                                                 CERPs Office
                                                                               or Academic Course         Date(s)
            (Title of Program or Activity)                Organization                                              Awarded Use
                                                                                      credits
  1      Communicating Better with Coworkers Memorial Medical Center                    N/A               7/18/07      2.00
  2          Leadership Skills for Nurses                    AONE                       N/A               9/15/08      4.00
  3                Charge Nurse                         Tri-West Hospital               N/A               3/15/09      2.00
  4
  5
  6
  7
  8
  9
 10

                                                                                                                   CERPs Office
      Committee Work / Leadership Roles                               Organization                        Date(s)
                                                                                                                  Awarded Use
  1          Infection Control Committee                         Memorial Medical Center                 2006-2007 10.00
  2      Evidence-Based Practice Committee                       Memorial Medical Center                 2007-2008 10.00
  3
  4
  5
  6
  7
  8
  9
 10

          Professional Membership                                                                                    CERPs Office
                                                       Membership Number             Membership Period
              (Name of Organization)                                                                                Awarded Use
  1                        AACN                             123456                   June 2006 - June 2009            9.00
  2
                                                                                                Category C total:      37.00
                        Category             Min/Max    Number of CERPs
                           A                  60-80         84.00
                           B                  10-30         31.50
                           C                  10-30         37.00
                         Grand Total (>100):                152.50

By signing below I affirm that the information listed on this CERP Log is true and correct.

  Signature: ___________________________________                                     Date: ________________

         1591e7c8-9a02-4f67-806e-d1e70775e4a4.xls                8 of 8                                             7/28/2011

				
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