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Volunteer Nurse Sample Application Letter document sample
Document Sample
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: ________________
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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
04d3c023-fde8-49f9-9c4b-12b0021d42f5.xls 5 of 8 10/13/2011
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
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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: ________________
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