Regional Pdrp Applicant Consent Form (A1)

REGIONAL PDRP APPLICANT CONSENT FORM (A1)

Proficient/Expert/Accomplished Levels

Name: Organisation:

Please complete the form by ticking the appropriate boxes and signing.

Include this form in your portfolio.

Thank you for submitting your Professional Portfolio and completed workbook for assessment at Level.

Please complete the following:

CONSENT FOR PORTFOLIO TO LEAVE PREMISES

I am willing for my portfolio and associated documentation to be removed from my organisation’s premises if required and kept as securely as possible. I understand that all steps will be taken to maintain the safety and privacy of my portfolio and that I can request its return at anytime.

Yes

RETURN OF PORTFOLIO

At the end of the assessment process your portfolio can be collected from the PDRP office or you may wish to have it sent via internal mail. This would be at your own risk.

MODERATION OF SUBMITTED PORTFOLIOS

The PDRP requires portfolios to be moderated to maintain consistency and objectivity of the process. One in every 10 portfolios will be reviewed by one of the PDRP Assessors who will moderate the original assessor(s) of your portfolio. All new assessors will have their assessments moderated initially. The moderation process does not affect the outcome of your assessment. Your portfolio may be selected for this process.

I understand and agree with the moderation process.

Yes

I understand that if a new assessor evaluates my portfolio, that a senior assessor will also assess my portfolio. The new assessor may use their assessment of my portfolio as an example of work completed in their Open Polytechnic studies. I agree to have a new assessor evaluate my portfolio.

Yes

The assessment will be carried out as soon as possible and should take no longer than
10 weeks.

All assessors have undertaken a recognised national qualification which requires objectivity, consistency and fairness. It is preferable that the assessor(s) do not know you, or recognise you through your portfolio. Attached is a list of all assessors for the Regional PDRP. To assist us with the selection process, could you please download this list, cross out any person you have worked closely with, been a line manager of, or who has been a personal friend.

It is not unusual for your assessor(s) to contact you for clarification or for extra evidence before a decision is made. This contact is generally by phone, but you may request a meeting.

When your portfolio assessment has been completed, you will be contacted with the decision, which will be one of the following:

Decisions

Endorsement of Progression

This means criteria for the applied level have been successfully met.

ReservedDecision

This means that the assessor is confident that you are practising at the level you have applied for, but further documented evidence is needed. You are given a timeframe of
6 weeks to provide this.

Non-Progression

This means that your assessor is confident that the criteria for that level have not yet been met. Guidelines may have not been adhered to or there are clear gaps in evidence that prevent a fair decision. Your assessor will clearly tell you which areas require further development and make some suggestions. If you wish to appeal the decision or the process, this procedure is outlined on the website or in the PDRP Policy.

Appeals

All applicants will have detailed feedback from their assessment, which should override the need for an Appeals Process. If you disagree with the decision, you should write a letter of appeal to the PDRP Coordinator. The appeal should be lodged within 7 working days of decision using an Appeal Notification Form (A6). On receipt of this letter, the PDRP Coordinator will request two new assessors to re-assess the portfolio.

The new assessors will not be told of the original outcome. If the decision by the new assessors is that you have been unsuccessful, you may decide to continue with the appeal. An Appeals Panel will be formed and those present will interview you and the assessors. On completion of this process, a written report outlining recommendations will be sent to you with copies to the PDRP Assessors, PDRP Advisory Committee and the Nurse Coordinator-PDRP.

The decision of the Appeals Panel is final and binding.

NB: The assessment will not be able to proceed until this this form has been completed.

Please ensure that all sections of this form are completed and signed. Details of your PDRP application are loaded onto our database to assist with our reports to Nursing Council to remove you from their audit process. For CDHB staff, details are also updated and placed on the payroll system to ensure information is correct for payment processing.

Signature: _ Date: ____

List of PDRP Assessors as at October 2016

(Please cross out names of staff you may know and/or work closely with)

G:\Division\SDU\COMMON\PDRP\Assessment process\Application Consent Form – October 2016

CDHB

Margaret Burns

Michelle Casey

Jane Clarke

Stephanie Cook

Janette Dallas

Tania Freeman

Jo Greenlees-Rae

Becky Hickmott

Suzanne Johnson

Jacinda King

Jenni Manuel

Ashburton and Rural

Lisa Campbell

Heather Cullimore

Hayley Creighton

Amanda Van Asperen

Burwood Hospital

Helen Bloomer

Fiona Davie

Kerry Jones

Dinesh Lal

Karen Marshall

Rachel Marshall

Kirstie Ross

Karen Stenhouse

Lynda Te Momo

Sue Williamson

Rebecca Winsor

Diane Wood

Stella Yaxley

Medical Surgical

Heather Anderson

Amanda Berry

Anna Bush

Karen Collins

Sharon Devon

Sharron Ellis

Pam Eaden

Sue Fawcett
Courtney Ford

Pip Francis

Ulrich Frank

Jacqui Gapes

Maggie Glasgow

Joanne Gore

Faye Greenwood

Carmel Harris

Neil Hellewell

Kirsty Humm

Tina Knutson

Carol Lechte

Julie Livesey

Charlotte Matthews

Rhonda Mikoz

Jill Oetgen

Linda Payne

Stephanie Pegg

Bronwyn Perry

Rommel Principe

Sandy Richardson

Jo Saunders

Fran Smith

Jenny Stewart

Olivia Strachan

Louise Sue

Lorraine Trebilcock

Felicity Turner

Robyn Van der Lely

Judy Ward

Janeen Williams

Ren Xiaoyong

Specialist Mental Health

Ian Averill

Tanya Ewart

Gail Houston

Sharon Isherwood

Cathy King

Carolyn Murray

Helen O’Connor

Phil Patira

Jane Patterson

Sam Rees

Claire Roelink

Cassandra Staps

Heather Symes

Simone Verburg

Jason Watson

Mary Woods-Morgan

TPMH

Helen Denby

Sue Holland

Yvonne Marr

Sarah Maxted

Women and Children’s

Tracey Bruce

Edna Byron

Patricia Connell

Tina Cook

Victoria Cullens

Anthea Franks

Linda King

Aimee MacKey

Donna Murray

Nicola Scott

Nurse Maude

Margaret Patterson

Philippa Sarjeant

Josie Tait-Jamieson

South Canterbury DHB

Anneke Clarke

Judy Cooper

Karen Foster

Gill Graham

Ally Hale

Sue Morrow

Jane Procter

Megan Stark

Tracey Worthington

St. George’s Hospital

Marilyn Casey

Sue Claridge

Wendy Davie

Paul Donohue

Alison Fleetwood

Aimee Librado

Kate Goodrick

Sue PRescott

West Coast DHB

Kas Beaufill

Chris Black

Elaine Neesam

Diane Pollard

Julie Ritchie

Helen Rodger

Bruce Tomlinson

Department of Corrections

Kirsty Fraser

Fiona Irving

Lyn McIntyre

Stephanie Muir

Linzi Sargant

Kay Sloan

Healthcare NZ

Norma Crooks

Rose McConchie

Kelly Robertson

Juliet Nelson

Pegasus Health

Anne-Marie Baird

Gill Currie

Di Bos

Sue Hart

Karen Gilchrist

Louise Weatherall

NMDHB

Wendy Adams

Sue Addison

Ingrid Archibald

Jocelyn Archer

Bridgett Baldwin

Pippa Babb

Anne-MarieBallagh

Carolyn Bennison

Jane Besley

Mary Bezant

Carol Biggs

Margie Burt

Tricia Colling

Dee Emmet

Morag Fisher

Jan Gould

Sharon Hawken

Jane Heather

Jessica Irvine

Ruth Jarman

Jenny Kane

Sue Lush

Glenis McAlpine

Sandy McLean-Cooper

Diane McLeod

Shirley Roberts

Hilma Schieving

Pamela Shadlock

Sue Smart

Angela Taylor

Melanie Terry

Annie Wallace

Susannah Visscher

SDHB

Rebecca Aburn

Jenny Bishop

Trish Bloxsom

Maria Baynes

Victoria Bryant

Jacqui Cooke

Katherine Clarkson

Debz Cracknell

Christine Crawford

Justine Dahlenburg

Kerry Davis

Lesley Dennison

Jo Dobson

Nicola Dowling

Mary Fahey

Richelle Fogarty

Lara Gleeson

Linda Grady

Mike Hammond

Chris Hayde

Robyn Hewlett

Rhonda Johnson

Robyn Kelly

Allison Lang

Cynthia Langford

Jillene Lee

Rachel Linton-Mapp

Christine Lundy

Laurie Mahoney

Ruth Manning

Katherine Martin

Shirley McKewen

Maxine Mitchell

Prue Muschamp

Sue O’Brien

Rowena Paterson

Mel Rackham

Glenda Rickerby

Grant Ritchie

Sharon Sandilands

Linda Smillie

Alison Stewart-Piere

Chris Still

Jo Robertson Smith

Pauline Stringer

Julie Symons

Helen Thompson

Jenni Topliss

Carolyn Upston

Rosalie Wright

Rannerdale Veteran’s

Care

Vivienne Erickson

Kaupapa Maori & Pacific NGO Collective

Elly Grant

Oxford Women’s Health

Debra Parr

Forte Health

Jane Barnett

Intus

Cathy Long

Jess Wolfenden

Nelson Bays Primary Health

Andrea Chapman

G:\Division\SDU\COMMON\PDRP\Assessment process\Application Consent Form – October 2016

Name: Organisation:

Signature: ___ Date: ______

List of PDRP Assessors as at October 2016

(Please cross out names of staff you may know and/or work closely with)

Signature: _ Date: ____