out of province practical nurse - College of Licensed Practical

Transcription

OUT OF PROVINCE
PRACTICAL NURSE
APPLICATION INSTRUCTIONS
Effective January 1, 2016
This instruction guide provides general information to
assist you in the application process. Further information
will be provided when your application has been assessed
to determine eligibility for registration. Information in this
guide is subject to change without notice.
OUT OF PROVINCE LICENSED
PRACTICAL NURSE
APPLICATION INSTRUCTIONS
Contents
1.
APPLICATION FOR REGISTRATION ....................................................................................................................................................................... 3
Personal/ Declaration ................................................................................................................................................................................................ 3
Nursing Education ..................................................................................................................................................................................................... 3
Initial Nursing Registration ........................................................................................................................................................................................ 3
Current Nursing Registration ..................................................................................................................................................................................... 3
Nursing Employment History .................................................................................................................................................................................... 3
Additional Application Requirements ....................................................................................................................................................................... 3
Registration Declaration ............................................................................................................................................................................................ 4
2.
OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION PROCESSING FEE .............................................................................................. 4
3.
VERIFICATION OF REGISTRATION ........................................................................................................................................................................ 4
Section 1 .................................................................................................................................................................................................................... 4
Section 2 .................................................................................................................................................................................................................... 4
4.
VERIFICATION OF NURSING EDUCATION (Required if graduated prior to 2009 or upon request by CLPNA) ...................................................... 4
Section 1 .................................................................................................................................................................................................................... 4
Section 2 .................................................................................................................................................................................................................... 5
5.
Declaration of Nursing Hours............................................................................................................................................................................... 5
Section 1 .................................................................................................................................................................................................................... 5
Section 2 .................................................................................................................................................................................................................... 5
6.
SPECIALIZED PRACTICE DECLARATION (Specialized Nursing Competencies) ....................................................................................................... 5
ADDITIONAL INFORMATION .......................................................................................................................................................................................... 5
Jurisprudence Exam (for applications received after January 1, 2016) ..................................................................................................................... 5
How does CLPNA assess applications for registration? ............................................................................................................................................. 6
OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION INSTRUCTIONS
Revised July 17, 2014
Page 2 of 6
This guide provides information on how to apply to become registered as a Licensed Practical Nurse (LPN) in Alberta. If you require additional
information please, contact our office at [email protected] .
These instructions will explain how to complete and submit the forms in the Application Package. Carefully read these instructions to avoid
unnecessary delays.
Key points to consider before starting the application process:






To be eligible to apply for registration, you must have obtained registration as an LPN in Canada (RPN in Ontario) or have completed a
Canadian PN program and have passed the CPNRE.
If you are not a new graduate, you are required to have obtained nursing hours in the past 4 years or have current registration in
another Canadian jurisdiction.
Completion and submission of each form in the application package is required.
All documentation must be translated to English prior to submission to CLPNA.
When completing forms, print legibly using black ink.
You have a period of one year, from the date your application file is opened, to complete the application process. Your assessment
letter will have a deadline date within it that must be adhered to.
1. APPLICATION FOR REGISTRATION
Complete this four page form and submit directly to CLPNA along with the additional information required.
Personal/ Declaration
Complete personal information carefully and clearly, please print.

Provide a valid email address (mandatory) because communications and information will be sent to you by email.
Read the questions carefully.

If you have answered “Yes” to any questions, write a brief explanation on the space provided.

You will be notified, if any further documentation is required.
Nursing Education
Provide all the information requested regarding your original nursing education.

If you have successfully completed additional nursing education, such as courses not originally included in your nursing
program, you must provide the information required under the “Additional Nursing Education” section of the form. This will
assist CLPNA in the assessment of your nursing education and experience. You do not need to send any additional
documents for post-basic nursing education until requested to do so by CLPNA.
Initial Nursing Registration
Provide all information requested regarding your initial (original) place of nursing registration.

Indicate the province/state/country where you obtained your initial registration.
Current Nursing Registration
Provide all information requested regarding your current nursing registration.

If you are currently registered with the same nursing board as your initial registration, you must provide the information
required.

If you are currently registered with more than one nursing board, provide the information for each of the nursing boards.

If you are currently not registered anywhere, provide the information of the last nursing board you were registered with.
Nursing Employment History
Provide information for all nursing employment in the past four years.
Additional Application Requirements
Use the checklist provided on page 3 of the Application for Registration to verify what you need to submit.
Revised November 30, 2015
Page 3 of 6
Registration Declaration
Read carefully, sign and date your Application for Registration prior to submitting to CLPNA.
2. OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION PROCESSING FEE
Submit payment of $210 to CLPNA. Options for application fee payment are as follows:

Complete the Credit Card Authorization form included with the application package.

Bank draft, or money order, made payable to CLPNA.

Cash or Debit, if paying in person at CLPNA office. (Do not mail)

Application Fees are non-refundable.

Ensure fees are in Canadian Funds.
Online profile
Once the Application for Registration form and $210 Application fee is received,
an online profile will be created and your login instructions and information will
be emailed to you. This profile will enable you to check the documents received
and outstanding for your application. It is your responsibility to check the status
and follow-up on the documents outstanding for your application.
3. VERIFICATION OF REGISTRATION
The purpose of this form is to verify initial and current nursing registration.

Current nurse registration in any province/state.

If you are a Canadian LPN new graduate and have successfully completed the CPNRE, request the regulator in your home jurisdiction to
complete this form and send it to our office. They should provide all of the information with exception to the registration information
portion.

These documents may be received from the other regulator by mail or email

You may need to make more than one copy of the Verification of Registration form depending on how many board(s) you have current
registration as a nurse.
Section 1
Complete this section to authorize the board(s) to provide the necessary registration information to CLPNA. Send the completed form to the
appropriate nursing board(s) to complete Section 2.
Section 2
The board will complete Section 2 and mail the form directly to the CLPNA office.
4. VERIFICATION OF NURSING EDUCATION
(Required if graduated prior to 2009 or upon request by CLPNA)
The purpose of this form to verify you have completed nursing education.
Section 1
Complete this section to authorize the school(s) to provide the necessary information to verify nursing education. Send the completed form
to the appropriate educational institution to complete Section 2.
Page 4 of 6
Section 2
The school will complete Section 2 and mail the forms to the CLPNA office.

Please ensure that the documentation submitted to CLPNA has been translated into English if the original is in a different
language.

Photocopies and/or faxes of this form from the school will not be accepted.
5. Declaration of Employment Hours
The purpose of this form is to verify nursing practice hours that you have acquired in the previous four (4) years.
Section 1
Complete this section to disclose the employers, dates worked, position title, and hours worked.
Section 2
Declaration of hours – this must be signed and dated to proceed with your application. You must attest that the information you have
provided is true and accurate to the best of your knowledge. CLPNA reserves the right to verify practice hours with current and past
employers.
6. SPECIALIZED PRACTICE DECLARATION (Specialized Nursing Competencies)
In Alberta, certain areas of practice are considered specialized nursing competencies. For an individual to work in a specialized area of practice,
authorization must be granted by CLPNA. If you do not have a specialized practice area of practice (indicated below), you are not required to
complete this form.
CLPNA Specialty Authorization is required for
nursing practice in the following areas:
Advanced Orthopedics
Operating Room
Immunization
Advanced Foot care

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Read the Specialization Information form carefully to determine if you require authorization.
Submit the appropriate documentation to prove you have completed the required education.
Please ensure the documentation submitted to CLPNA has been translated into English if original is in a different language.
rd
For more information about these specialty areas of nursing practice, please view Competency Profile for LPNs – 3 edition available
under ‘Resources’ on CLPNA’s website.
ADDITIONAL INFORMATION
Jurisprudence Exam (for applications received after January 1, 2016)
Prior to being approved for registration in Alberta you must complete the Jurisprudence exam. The Jurisprudence Exam information is
included in this package as separate instructions.
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How does CLPNA assess applications for registration?
When all forms have been submitted to CLPNA, your application will be assessed to determine eligibility for registration as a Licensed Practical
Nurse in Alberta.

Assessment may take up to 10 business days.

The assessment decision will be provided to you in writing via your email.

If you are eligible for an Active registration, you will be advised to complete an “Initial Registration Form” and pay a registration fee of
$405.00.

Should you disagree with the decision, you may request a review by CLPNA Council. The fee for review is $750.
Determining Substantial Equivalent Competence
Substantial equivalent competence is the term used by CLPNA to describe the combination of education, experience, practice or other
qualifications that demonstrates the competence required for entry-to-practice as an LPN in Alberta. CLPNA’s assessment of substantial
equivalent competence involves the review of nurse registration verification and other documents which provide information regarding
competence to practice. CLPNA looks for evidence that the applicant currently possesses the competencies which will allow the individual to
fulfill the role and responsibilities of the LPN.
If gaps are identified in education or currency of practice (nursing hours) on review of the applicant documentation, CLPNA will decide
whether additional nursing education will be required before an applicant may pursue further steps in the registration process. Depending
upon the nature and extent of any identified gaps, the assigned education may be in the form of one or more nursing courses. However, if
the competency gaps are extensive the applicant may be advised to complete a refresher program.
Possible assessment decisions are:
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The applicant is notified of registration eligibility to obtain an Active Practice Permit
The applicant is notified of registration eligibility to obtain an Active Practice Permit with conditions to complete a course where
an educational deficit in one or all five of Medication Administration, Infusion Therapy, Adult Health Assessment, maternity
and/or pediatrics.
The application can be deferred pending further information or assessment – such as English Language Proficiency Testing.
The application can be denied – such as in cases of not meeting good character requirements or fitness to practice requirements.
Practice Permits with Conditions:
The following information is to provide clarity regarding the Active Practice Permit with Conditions and the parameters that must be
followed, while an applicant is practicing and studying to obtain an Active Practice Permit without Conditions in Alberta. If you are issued a
permit with conditions, you will need to meet the conditions within the time specified by CLPNA, or you may not be eligible to renew
your Practice Permit.
Health Assessment – practical nurse programs in Canada/United States have some level of health assessment, although there are gaps in the
depth of this knowledge. Individuals who are restricted in Health Assessment must work within their competence when performing
assessments (supervision with another regulated health professional is recommended).
Medication Administration/Pharmacology – applicants who have not completed a formal education program in medication
administration/pharmacology are NOT permitted to administer medications in Alberta until they have successfully completed the
appropriate certification. If the applicant has knowledge and experience in certain elements of medication administration they must verify
this with their employer and direct supervisor to identify the depth of their role in medication administration within the practice setting (i.e.,
administration of suppositories, creams, drops, etc.).
Infusion Therapy – applicants who have not completed formal education in infusion therapy are NOT permitted to monitor or care for
infusions in Alberta until they have successfully completed the appropriate education.
Maternity/Pediatrics – the applicant is NOT permitted to be assigned to maternity or pediatric patients until conditions are completed and
approved by CLPNA.
For more information and further resources contact our Out of Province Department at [email protected].
Page 6 of 6
Jurisprudence Exam
Instructions & Information
This instruction guide provides general information to
assist you in the application process. Information in this
guide is subject to change without notice.
JURISPRUDENCE EXAM
INSTRUCTIONS & INFORMATION
Contents
1.
Purpose of Jurisprudence Exam, Goals and Objectives ............................................................................................................. 3
1.1
Learning Objectives .................................................................................................................................................................... 3
1.2
Topics ......................................................................................................................................................................................... 3
1.3
CLPNA Blueprint Competency Statements – June 2013 ............................................................................................................ 3
2.
Is it a Requirement for Registration ........................................................................................................................................... 3
3.
Exam Resource Guides ............................................................................................................................................................... 4
3.1
Online CLPNA Jurisprudence Exam Study Guide........................................................................................................................ 4
3.2
Tool for LPNs on the USB Key .................................................................................................................................................... 4
4.
How Do I Write the Exam ........................................................................................................................................................... 4
5.
Is there a fee for the jurisprudence examination? .................................................................................................................... 4
6.
When can applicants write the examination? ........................................................................................................................... 4
7.
How long does it take to complete the examination? ............................................................................................................... 4
8.
How is the jurisprudence examination scored? ......................................................................................................................... 4
9.
When do I receive my exam results? ......................................................................................................................................... 5
10.
What are the minimum computer requirements to take the examination? ............................................................................. 5
11.
How do I apply for special accommodation to complete the jurisprudence examination? ...................................................... 5
12.
If I fail the jurisprudence examination, can I take it again? ....................................................................................................... 5
13.
Do I have to notify the College about my results? ..................................................................................................................... 5
14.
Any Further Questions? ............................................................................................................................................................. 5
15.
Appendix A ................................................................................................................................................................................. 6
JURISPRUDENCE EXAM APPLICATION INSTRUCTIONS
Revised JUNE 27, 2013
Page 2 of 6
1. Purpose of Jurisprudence Exam, Goals and Objectives
The Jurisprudence exam was designed to ensure licensed practical nurses in Alberta have the necessary knowledge to practice
nursing safely within the legislative framework that exists in Alberta and Canada and understand their professional role and
responsibilities within the profession.
1.1
•
•
•
1.2
•
•
•
•
•
•
•
•
•
1.3
Learning Objectives
To facilitate an understanding of the basic frameworks of Provincial (Federal) Health Care Systems
To increase awareness of current practice issues
To increase personal and professional confidence while adapting and integrating into new health care setting
Topics
Patient-centered care
Collaboration among healthcare providers
The role of the federal and provincial governments in the Canadian health care system
Understanding key legislation needed to inform nursing practice in Alberta
Patient safety issues and the LPN role
Planning for success in the healthcare workplace
E-ethical dilemmas
Communicating effectively in the healthcare workplace
Expectations surrounding professionalism and lifelong learning
CLPNA Blueprint Competency Statements – June 2013
The exam was created from the blueprint (Appendix A). Questions were written as “Knowledge” and “Application”
questions, the exam will be scored using 70 questions, but maybe up to 80 questions. This variable amount of questions
are field test questions and will not count towards your examination grade. The passing grade varies from 65-70% and
there is multiple exam forms.
Three competency domains were created.
 Self-Regulation
 Scope of Practice
 Professional Accountability & Responsibility
2. Is it a Requirement for Registration
The jurisprudence examination is a registration requirement as of January 1, 2013 for Internationally Educated Nurses. These
nurses were identified with the most significant need, as many of these nurses do not understand the legislative framework
that exists in Alberta within the practical nursing profession.
Internationally Educated Nurses must pass the jurisprudence examination as a condition of registration.
The jurisprudence examination will be a registration requirement for graduates from a practical nurse program in Alberta and
practical nurse applicants from another jurisdiction in Canada in 2015. The Jurisprudence Exam will provide additional
support to understanding their professional role and responsibilities as a practical nurse in Alberta.
Current members of the College are not required to complete the exam, but it will be available to take as Continuing
Competency learning in September 2013 by completing an application to take the Jurisprudence Exam.
JURISPRUDENCE EXAM INFORMATION & INSTRUCTIONS
Page 3 of 6
3. Exam Resource Guides
3.1
Online CLPNA Jurisprudence Exam Study Guide
The online CLPNA Jurisprudence Exam Study Guide is a tool individuals can utilize to study in preparation of jurisprudence
exam by reviewing a tutorial, listening to narrative and reviewing contents in detail. There is no cost associated with the
tool.
3.2
Tool for LPNs on the USB Key
The 'LPN Key to Self-Regulation' is a portable way to carry and consult documents that were only available in the CLPNA's
400-page Continuing Competency Program (CCP) Binder or in various locations on the CLPNA's website. New CLPNA
applicants receive the LPN Key as part of the initial registration process. The key contains document that the College
recommends as study materials. (Please note that documents on the USB key list may be revised or changed, it is each
nurse’s responsibility to monitor the list for any updates and ensure they review only the most recent versions of the
documents. If you do not have a key and would like to purchase one, they are $30 each for members by filling out an
order form with payment information.
It is highly likely that applicants will be able to successfully complete the jurisprudence examination within the allotted
time as long as they review all the materials in advance.
4. How Do I Write the Exam
Applicants assessed to write the Jurisprudence Exam will be provided with details about how to access the exam as part
of their registration process.
An email with a unique link will be provided to the applicant from the CLPNA, where they can pay for the $50.00
examination fee. Once payment has been made the exam will start right away. You will not be able to stop or pause the
system and return. It must be written in one sitting and you are given four hours to complete the exam.
5. Is there a fee for the jurisprudence examination?
Yes. The fee for the jurisprudence examination is $50.00 (CDN) including applicable taxes. The fee is required each time an
applicant attempts to write the examination. Payment is made online by credit card through the secure examination
website.
6. When can applicants write the examination?
Once applicants have received instructions about how to access the jurisprudence exam, the individual can choose to take
the online exam at any time.
Once an applicant begins writing the exam, they cannot stop or pause the system and return. It must be written in one
sitting.
7. How long does it take to complete the examination?
Applicants have a maximum of 4 hours or 240 minutes to complete the examination. If you run out of time and do not
answer all of the questions, they will be marked on the responses that were provided up to that point.
8. How is the jurisprudence examination scored?
Results of the examination are provided by Overall Performance and then by Competency Domains. The Overall
Performance includes the actual percentage and provides you with the exam result of Successful or Not Yet Successful.
The Competency Domains will also include actual scores but will also provide recommendations of additional study, as
shown below.
Page 4 of 6
Recommendations for Additional Study
Low – Little, if any additional study recommended.
Medium – Some additional study may be helpful.
High – Additional study recommended.
9. When do I receive my exam results?
Applicants receive their exam result immediately after they submit their test answers. It is recommended you keep a copy
of the email with your examination results for your own records.
10. What are the minimum computer requirements to take the examination?
The jurisprudence examination site supports the latest versions of Safari, Firefox and Chrome, as well as Internet Explorer
7, 8 and 9. If one of these browser versions is not installed on your computer, there will be a message inviting you to
upgrade when you attempt to access the testing site.
11. How do I apply for special accommodation to complete the jurisprudence examination?
You can apply for special accommodation to complete the jurisprudence examination by notifying the College in writing of
your specific circumstances with a request for alternate arrangements. You may be required to provide supporting
documentation with your request.
12. If I fail the jurisprudence examination, can I take it again?
Yes. If you receive a Fail score for the jurisprudence examination, you can rewrite the examination. There is no limit on
the number of times you can write the examination or a restriction on how much time is taken between each attempt.
Applicants with Conditional Registration must be mindful that registration will lapse after one year from the date of issue
and are required to complete the Jurisprudence condition within the one-year timeframe. CLPNA may require individuals
to complete additional education and undergo a new application for registration to determine eligibility for licensure if
their practice permit expires and the condition has not been met.
13. Do I have to notify the College about my results?
No. Your jurisprudence examination results will automatically be submitted to the College. You will be able to go online
and see the Condition on your registration has been received, if you are successful in passing the jurisprudence exam.
14. Any Further Questions?
If you have read through all of these Frequently Asked Questions (FAQs) and your questions have not been answered,
please email [email protected] and submit your questions.
Page 5 of 6
15. Appendix A – Blue Print Competency Statements
Page 6 of 6
OUT OF PROVINCE
LICENSED PRACTICAL NURSE
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.
__________________________________________________________
E-mail Address (MANDATORY)
_____________________________________
Primary Language
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 previously?
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 health profession in Alberta or any other province, territory, state or country (excluding CLPNA)?
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 (excluding
CLPNA)?
Are you currently under investigation or involved in any proceedings, which could or has resulted in the encumbrance
of your nursing registration by:
Yes
No
5.
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
8.
Do you have any physical or mental condition or disorder that may impair your ability to provide safe, competent and
ethical care? If you have answered yes to question 8, answer the questions below; otherwise leave questions (a)
and (b) blank.
a. If “Yes”, are you under the care of a physician or healthcare team?
Yes
No
Yes
No
Yes
No
b.
If “Yes”, are you following medical advice?
If any circumstances change throughout the year, you are required to contact CLPNA.
OUT OF PROVINCE LICENSED PRACTICAL NURSE APPLICATION FOR REGISTRATION
Page 1 of 4
(Please Print: If you answered ‘YES’ to any question on the Personal Declaration, provide a brief
explanation.)
NURSING EDUCATION (Please Print: Provide all nursing programs taken, including both basic and refresher
programs.)
Name of Nursing Program
Language of Instruction
Start Date
(dd/mm/yy)
Graduation Date
(dd/mm/yy)
Name of Educational Institution
Address(Street No./City/Province/Country)
Phone (including area code)
Name of Nursing Examination
Language of Examination
Passed
Number of Times Examination
Written
Credential Received (example;
Degree, Diploma, Certificate)
 Yes  No
ADDITIONAL NURSING EDUCATION (Please Print: Provide all post basic programs and/or courses
completed. More than 3 please provide on a separate piece of paper.)
Name of Credential Received
Institution Name and Country
Start Date and Completion Date
INITIAL NURSING REGISTRATION (Please Print: Provide original registration information only, even if
registration is no longer current.)
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)
CURRENT NURSING REGISTRATION (Provide all places of registration (other than with CLPNA) or other regulated
profession(s) (ie. registered nurse, physiotherapist, midwife, paramedic, etc.). If you are not currently registered then
provide the most recent place of registration. More than 2 please provide on a separate piece of paper.
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)
Page 2 of 4
NURSING EMPLOYMENT HISTORY (Please Print: Provide all employers in the past 4 years. More than 4
please provide on a separate piece of paper.)
Employer Name and Phone
Address
Unit/Area of Responsibility (check applicable boxes)
Job Title/Position
Status (Full-Time, Part-Time, Casual)
Medical
Surgical
Obstetrics
Pediatrics
Start Date (dd/mm/yy)
End date (dd/mm/yy)
Mental Health/Psychiatry
Community
Gerontology/Long Term Care
Other___________________________________
Address
Job Title/Position
Medical
Surgical
Obstetrics
Pediatrics
End date (dd/mm/yy)
Community
Other___________________________________
Address
Job Title/Position
Medical
Surgical
Obstetrics
Pediatrics
End date (dd/mm/yy)
Community
Other___________________________________
Address
Job Title/Position
Medical
Surgical
Obstetrics
Pediatrics
End date (dd/mm/yy)
Community
Other___________________________________
ADDITIONAL APPLICATION REQUIREMENTS (You must also submit the following with your application
form or it may be considered incomplete, please verify.)
 I have included a clear copy of my birth certificate and/or passport. (Mail or Email; Do Not Fax)
 I have included a clear copy of my driver’s license, citizenship card, and/or permanent residence card. (Mail or Email; Do Not Fax)
 I have included the $210 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 understand all my documentation must be translated to English before it is submitted to the CLPNA office.
Page 3 of 4
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.
CONSENT TO REVOCATION/SUSPENSION OF REGISTRATION
I acknowledge and agree that the College may, at its option, immediately revoke, suspend or refuse to renew my registration if any information
contained in this application is inaccurate or incomplete until such 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. I agree to return my
registration and licensure to the College as requested in the event that my registration is revoked or suspended. I also acknowledge and agree
that I may be subject to disciplinary action, irrespective of whether my registration is revoked or suspended with the College, if I fail to provide
current, correct and complete information to the College in respect to 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 1 year from my
application date. I understand that after 1 year has lapsed I am required to reapply.
_______________________________________________________
Applicant Signature (do not print)
_______________________________________________________
Date (dd/mm/yy)
Page 4 of 4
OUT OF PROVINCE
VERIFICATION OF NURSING EDUCATION
Complete Section 1 and forward to your nursing school(s) to complete Section 2. Once completed, the form must be
mailed directly from the nursing school(s) to CLPNA. Copies will not be accepted and documents must be translated
to English. This form is mandatory for applicants who graduated prior to 2009. This form may be requested by the
CLPNA as needed to further assess educational competencies.
SECTION 1 (completed by applicant)
_____________________________________
______________________________________
_____________________________________
Middle Name(s)
_____________________________________
Maiden Name
______________________________________
Sex
 Female
 Male
______________________________________________________________________________
_____________________________________
_____________________________________
Province/State
______________________________________
Country
_____________________________________
_____________________________________
Telephone No.
______________________________________
Cell No.
_____________________________________
Primary Language
__________________________________________________________
E-mail Address
CONSENT TO RELEASE INFORMATION
I am seeking registration as a Licensed Practical Nurse in Alberta. I authorize ___________________________________ (name of Nursing School)
to complete Section 2 of this form and mail the required documentation directly to the College of Licensed Practical Nurses of Alberta (CLPNA).
___________________________________________
___________________________________________
Date (dd/mm/yy)
SECTION 2 (completed by nursing school)
NURSING EDUCATION (Please Print)
_______________________________________________________
_________________________________________________________
______________________________________________________________________________________
Address(Street No./City/Province/Country/Postal Code/Zip Code)
____________________________________
Language of Instruction
Credential Received
 Degree
____________________________________
Date of Admission (dd/mm/yy)
 Diploma
__________________________
Phone (including area code)
_____________________________________
Graduation Date (dd/mm/yy)
 Certificate
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF NURSING EDUCATION
Page 1 of 2
NURSING COMPETENCIES CONTINUED (please check if the following competencies were part of the
nursing program.)
Health Assessment
 Yes
No
Medication Administration/Pharmacology
 Yes
No
Infusion Therapy (maintenance of IV only)
 Yes
No
Subcutaneous Injections
 Yes
No
Pediatrics
 Yes
No
Maternity
 Yes
No
ACTING ON BEHALF OF THE NURSING SCHOOL
____________________________________________
Designate Name (please print)
_____________________________________________
Title
_________________________________
Signature of Designate
____________________
Date (dd/mm/yyyy)
_________________________________
Email
________________________________
Phone Number
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF NURSING EDUCATION
Place
Official
Stamp
or
Seal
Here
Page 2 of 2
OUT OF PROVINCE
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 emailed directly from the registration/nursing board(s) to
CLPNA. Copies will not be accepted.
_____________________________________
______________________________________
_____________________________________
Middle Name(s)
_____________________________________
Maiden Name
______________________________________
Sex
 Female
 Male
______________________________________________________________________________
_____________________________________
_____________________________________
Province/State
______________________________________
Country
_____________________________________
_____________________________________
Telephone No.
______________________________________
Cell No.
_____________________________________
Primary Language
__________________________________________________________
E-mail Address
EDUCATION (Please Print)
______________________________________
______________________________________
_____________________________________
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).
___________________________________________
___________________________________________
Date (dd/mm/yy)
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF REGISTRATION
Page 1 of 2
SECTION 2 (completed by registration/nursing board)
THIS CERTIFIES THAT (Please Print)
_____________________________________
______________________________________
_____________________________________
Middle Name(s)
_______________________________________________________________________
Nursing School/Educational Program
__________________________________________
Completion Date (dd/mm/yy)
_______________________________________________________________________
Educational Facility Address
Registered by  Examination  Endorsement
______________________________________
Initial Registration Date (dd/mm/yy)
______________________________________
Expiry Date (dd/mm/yy)
_____________________________________
Registration Number
______________________________________
Name of Examination Written
______________________________________
Date Examination Written (dd/mm/yy)
_____________________________________
Language of Examination
Number of Times Examination was Written_________
Current Status
Registered
Results
 Pass  Fail
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?
Yes
No
3.
Has the applicant ever voluntarily surrendered their registration with the board and/or any other
jurisdiction?
Yes
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
No
If “Yes” is the answer to any of the questions, please attach documentation outlining action(s) taken.
ACTING ON BEHALF OF REGISTRATION, BOARD, OR COUNCIL
______________________________________
Signature of Registrar/Designate
____________________________
Title
_______________________________________
Print Name
_________________________________________________
Email
______________________________________
Name of Licensing Authority/Jurisdiction
Place
Official
Stamp or
Seal Here
_______________________________________
Date (dd/mm/yy)
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF REGISTRATION
Page 2 of 2
OUT OF PROVINCE
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.
_____________________________________
______________________________________
_____________________________________
Middle Name(s)
_____________________________________
Maiden Name
______________________________________
Sex
 Female
 Male
______________________________________________________________________________
_____________________________________
_____________________________________
Province/State
______________________________________
Country
_____________________________________
_____________________________________
Telephone No.
______________________________________
Cell No.
_____________________________________
Primary Language
__________________________________________________________
E-mail Address
EMPLOYMENT DETAILS (Please Print)
Facility Name
__________________
__________________
End Date (dd/mm/yy)
______________________________
Job Title/Position
___________________________________
Supervisor Name
___________________________________
Supervisor Job Title/Position
EMPLOYMENT HOURS
Year Employed
Total Hours Worked
2015
2014
Medical
Surgical
Community
Obstetrics
Pediatrics
Other________________________________
2013
2012
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF EMPLOYMENT
Page 1 of 2
EMPLOYMENT DETAILS (Please Print)
Facility Name
__________________
__________________
End Date (dd/mm/yy)
______________________________
Job Title/Position
___________________________________
Supervisor Name
___________________________________
Supervisor Job Title/Position
EMPLOYMENT HOURS
Year Employed
Total Hours Worked
2015
2014
Medical
Surgical
Community
Obstetrics
Pediatrics
Other________________________________
2013
2012
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:________________________________________
OUT OF PROVINCE LICENSED PRACTICAL NURSE VERIFICATION OF EMPLOYMENT
Date:____________________________________
Page 2 of 2
OUT OF PROVINCE
SPECIALIZED PRACTICE DECLARATION
_____________________________________
______________________________________
_____________________________________
Middle Name(s)
_____________________________________
Maiden Name
______________________________________
Sex
 Female
 Male
______________________________________________________________________________
_____________________________________
_____________________________________
Province/State
______________________________________
Country
_____________________________________
_____________________________________
Telephone No.
______________________________________
Cell No.
_____________________________________
Primary Language
__________________________________________________________
E-mail Address
SPECIALIZATION INFORMATION
Under the Health Professions Act, Restricted Activities are health services that pose significant risk and are identified to require a level of
professional competence to be performed safely. Regulated professionals must be authorized by their College to perform Restricted Activities.
Most Restricted Activities are authorized through basic LPN education; however, there are five areas of Specialized Practice that are monitored
by the College of Licensed Practical Nurses of Alberta (CLPNA). The LPN must be granted authority by the CLPNA to engage in Specialized Practice
in the following areas:





Advanced Orthopedics
Operating Room Nursing / Perioperative Nursing
Immunization
Advanced Foot Care
Renal Dialysis (employer provided)
There are differences in the education for these five Specialized Practice areas.



Approved or equivalency in education must be achieved in Advanced Orthopedics, Operating Room Nursing, and Immunization prior to
authorization to practice these areas.
Advanced Foot Care recognized education or equivalency is assessed and noted on the applicant’s file.
Renal Dialysis education can only be authorized through employer education therefore cannot be assessed by CLPNA.
Please indicate if you wish to have equivalency assessed in Advanced Orthopedics, Operating Room Nursing, Immunization, or Advanced Foot
Care by completing the Declaration of Specialization and requesting original educational transcripts and/or certificates to be sent to the CLPNA. If
you do not have a specialized practice area of practice, you are not required to complete this form.
Once your specialization is approved by the CLPNA, it will be indicated on your practice permit and will be displayed on the Public Registry. For a
more complete explanation of Specialized Practice Restricted Activity authorizations, view Practice Statement #7 on the CLPNA website.
OUT OF PROVINCE LICENSED PRACTICAL NURSE SPECIALIZED PRACTICE DECLARATION
Page 1 of 2
DECLARATION OF SPECIALIZATIONS (Please Print: check applicable boxes )
Specialization
Educational Facility
Completion Date
Original Transcript or
Certificate Submitted
 Advanced Orthopedics
 Operating Room
 Immunization
 Advanced Footcare
DECLARATION
I hereby declare 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 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.
____________________________________________________
Signature of Applicant (do not print)
______________________________________________________
Date
FOR OFFICE USE ONLY
Date
Approval
Comments
Alinity Entry Date
OUT OF PROVINCE LICENSED PRACTICAL NURSE SPECIALIZED PRACTICE DECLARATION
Page 2 of 2
OUT OF PROVINCE
CREDIT CARD AUTHORIZATION FORM
PAYMENT INFORMATION (please print)
Date:
Payment Description:
Amount:
$210.00
OOPS APPLICATION FEE
PERSONAL INFORMATION (please print)
Name:
Address:
City:
Province:
Phone:
Cell:
Postal Code:
Email:
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:
Signature:
OUT OF PROVINCE LICENSED PRACTICAL NURSE CREDIT CARD AUTHORIZATION FORM
Credit Card:
VISA Mastercard
Date:
July 17, 2014
Page 1 of 2
THIS PAGE INTENTIONALLY LEFT BLANK
INTERNATIONALLY EDUCATED NURSES: APPLICATION FOR REGISTRATION
Revised: August 23, 2012
Page 2 of 2\

out of province practical nurse - College of Licensed Practical

Transcription

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