NCPD accrediation Appraiser Application

Application for Nursing Continuing Professional Development Accreditation Appraiser

To be considered as an appraiser candidate a complete application portfolio must be completed.

An Application Portfolio includes the following:

Completed Application Form on Survey Monkey
Letter of Support from a representative of an ANCC accredited or approved organization or an ANCC Accreditation Program Appraiser - Please send to accreditation@ana.org
Curriculum Vitae -Please send to accreditation@ana.org

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* 1. Applicant Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Present Position (Title & Description)

Organization

Title

Position Description

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* 3. Is your organization accredited by ANCC and/or do you serve as a volunteer with an accredited organization?

Yes (Accredited Provider)

Yes (Accredited Approver)

Yes (Accredited Approver & Provider)

Yes (Approved Provider through an Accredited Approver)

Yes (Serve as a volunteer in another organization)

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* 4. Professional Formal Education

Degree

Year awarded

Institution

City/State

Major

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* 5. Professional Formal Education

Degree

Year awarded

Institution

City/State

Major

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* 6. Professional Formal Education

Degree

Year awarded

Institution

City/State

Major

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* 7. Professional Formal Education

Degree

Year awarded

Institution

City/State

Major

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* 8. Please list the state where you hold an unencumbered license to practice as a registered nurse:

State:

RN license Number:

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* 9. Are you certified in Nursing Professional Development?

Yes

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* 10. Are you certified in any other area?

Yes

Please specify which certification

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* 11. Please check all those settings listed below in which you have been involved in continuing nursing education:

Hospital Acute Care

Community Health

Outpatient Settings

Continuing Education Company

State or Federal Nurses Association

Home Care/Hospice

Long Term Care

School Nursing

Commercial Product Suppliers

Specialty Nurses Association

Other (explain below)

Please specify

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* 12. Please describe your activities related to continuing nursing education

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* 13. Which of the following best describes your experience in Program Evaluation:

I have developed and critiqued either academic, service, state, federal regulatory standards, for example, JCAHO, CCNE, NLNAC, HIPAA, and /or Board of Nursing

I have served as an Accreditation Appraiser, Magnet Appraiser, JCAHO appraiser, academic appraiser, CCNE site visitor, or on a State Board of Nursing or other regulatory body

I have served on the Commission on Accreditation (COA)

I have served on the ANCC Accreditation Review Committee (ARC)

I have served on a survey preparation team for either an academic or regulatory site visit (Please describe below)

I have some work experience in the interpretation and application of standards (Please describe below)

I have little experience in the interpretation of standards (Please describe below)

please specify if requested from areas above

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* 14. Which of the following best describes your experience with on the job Project Management:

I have led teams to achieve challenging project goals such as e-learning projects, web casts, developing and utilizing learning systems, developing and utilizing record-keeping systems for continuing nursing education, accreditation teams, etc.

I have been an active member of teams which utilized high level communication, prioritization, and critical thinking skills to accomplish complex tasks or meet complex goals (Please describe).

I have experience in utilizing computer skills such as word processing, e-mail, e-mail attachments to implement project management (Please describe).

have little experience in project management.

Please specify if requested from above

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* 15. Which of the following best describes your experience with Information Management:

I have experience in analyzing data and writing reports.

I have little experience with information management.

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* 16. Which of the following best describes your experience with Adult Learning?

I have experience analyzing continuing education activities and further developing them to meet current and future trends.

I have some experience with evaluating continuing education activities in relation to desired outcomes.

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* 17. Since the Accreditation Appraisal Process is a team-based process, please provide a brief description of your experience on teams and why you are an effective team member in six lines or less.

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* 18. If you have experience serving as a team leader, describe your experience in six lines or less.

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* 19. Use this space to briefly describe why you think you would be an asset to the ANCC Accreditation Program as an appraiser.

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* 20. Are you a member of ANA or an ANA State Nurses Association/Constituent Member Association?

Yes

If yes, please specify

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* 21. If appointed, I agree to participate in web-based training sessions and serve as an ANCC Accreditation Appraiser pursuant to the ANCC Accreditation Agreement.

The information provided above is accurate to the best of my knowledge. I understand that any knowing submission of incorrect information will result in my immediate termination as an ANCC Accreditation Appraiser.

A response of I agree in the box below serves as the electronic signature of the applicant completing this application.

I agree

I disagree