EN MODERATION FORM – New/Old Scope

Portfolio Moderated Details:
Name of Portfolio Applicant: ______
First Name(Please Print)Last Name
Designation:Enrolled NurseLevel applied for:______
Assessor 1:______
First Name(Please Print)Last Name
Assessor 2:______
First Name(Please Print)Last Name
Moderator: ______
Criteria / Consistent 1st Party
Consistent 3rd Party
Evidence
Y/N / Comments / Agree with Outcome (Y/N)
CDHB Competencies i.e. CPR, IV Cert., Fire Training, Second Checker, etc.
Clinical Practice Hours
Relevant evidence within last three years
Area Specific Competencies
*Some clinical areas have added mandatory competencies.
Completion of training on Code of Conduct and Professional Boundaries
*As Per NCNZ requirement July 2015
Domain 1 Criteria / Consistent 1st Party
Consistent 3rd Party
Evidence
Y/N / Does evidence reflect level of practice applied for? / Agree with Outcome (Y/N)
Competency 1.1
Competency 1.2
Competency 1.3
Competency 1.4
Competency 1.5
Competency 1.6
Domain 2 Criteria / Consistent 1st Party
Consistent 3rd Party
Evidence
Y/N / Does evidence reflect level of practice? / Agree with Outcome (Y/N)
Competency 2.1
Competency 2.2
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Competency 2.3
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Competency 2.4
Competency 2.5
Competency 2.6
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Domain 3 Criteria / Consistent 1st Party
Consistent 3rd Party
Evidence
Y/N / Does evidence reflect level of practice? / Agree with Outcome (Y/N)
Competency 3.1
Competency 3.2
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Competency 3.3
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Domain 4 Criteria / Consistent 1st Party
Consistent 3rd Party
Evidence
Y/N / Does evidence reflect level of practice? / Agree with Outcome (Y/N)
Competency 4.1
Competency 4.2
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
Competency 4.3
New Competency by Nursing Council - NOT ASSESSED FOR ENs IN RESTRICTED SCOPE
ExtraCriteria for Proficient/Expert (if applicable) / Evidence provided (e.g. PA or other)
Y/N / Does evidence reflect level of practice? / Agree with Outcome (Y/N)
Feedback Assessor 1:
Overall Comments:
Future Suggestions/Recommendation Action to be taken (if required):
Feedback Assessor 2:
Overall Comments:
Future Suggestions/Recommendation Action to be taken (if required):
Date:______Designation:______
Name of moderator:______
First Name(Please Print)Last Name
Contact Details:______Time taken for moderation: ______
Signature of Moderator:______

G:\Division\SDU\COMMON\PDRP\Moderation Guidelines - Forms\RN 2010 moderation form NEW.doc29/09/18