2018 HPNA Fellow in Palliative Nursing Care Application

2018 HPNA Fellow in Palliative Nursing Care Application

Use the TAB Key to move from block to block when filling out this application

Name: Click here to enter text. / Credentials: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text. / State: Click here to enter text. / Zip: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text. / Date: Click here to enter a date.

Application Requirements

1.  Applicant must be a Licensed Registered Nurse.

2.  Applicant must be a current member of the Hospice and Palliative Nurses Association (HPNA) with evidence of continuous membership and active participation in the Association over the past five (5) years. HPNA Membership must be maintained to keep Fellow status.

3.  Current HPNA Board members at time of application are not eligible.

4.  Applicant must provide evidence of progressive leadership over the past five (5) years with professional activity in the field of palliative nursing.

5.  Applicant must show a significant commitment to the advancement of the art and science in the field of palliative nursing.

6.  Applicant must provide two (2) letters of recommendation from nursing peers (may be sent with application or separately – must be received by deadline).

7.  Applicant must provide a CV or resume with the application.

8.  A nonrefundable application fee of $75 is required.

9.  Accrual of a minimum of 200 points as defined on the HPNA Fellows application is necessary for consideration.

10.  Applicant must achieve a minimum of 40 points for HPNA, Hospice & Palliative Credentialing Center (HPCC), Hospice & Palliative Nurses Foundation (HPNF) related activities. (Section I.)

11.  Completed applications will be reviewed for quality of activities and participation; quantitative score of 200 or greater does not guarantee Fellow designation.

12.  Application and all required components must be RECEIVED in the National Office no later than 11:59 PM EST on SEPTEMBER 10, 2017. Only completed applications received by the deadline will be considered.

13.  Application may be emailed or mailed.

Contact Person:

Holly Nesbitt, Hospice and Palliative Nurses Association

One Penn Center West – Suite 425

Pittsburgh, PA 15276-0109

Phone: 412-787-8211, Fax: 412-787-9305, Email:

Section I

Activities in Support of or Service to HPNA, HPCC, or HPNF

(Use the TAB Key to move from block to block, use ENTER/RETURN when filling in the block if needed)

1. List the AAHPM/HPNA Annual Assembly, HPNA Clinical Practice Forum, or NHPCO/AAHPM/HPNA Virtual Conference meetings you have attended.

Meeting / Month/Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(1 point per complete meeting, maximum 5 points)

2. List any recent activity you participated in and earned contact hours through HPNA (E-learning, audio web conferences, Clinical Practice Forum, JHPN, etc.).

Activity / Date
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.

(1 point per activity, maximum 5 points)

3. List abstracts presented as poster/papers at an AAHPM/HPNA Assembly or HPNA Clinical Practice Forum.

Title / Meeting / Month/Year
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.

(5 points per presentation, maximum 10 points)

4. List authored research or clinical review articles you have published in the Journal of Hospice and Palliative Nursing (JHPN) or the Journal of Palliative Medicine (JPM).

List Articles in AMA Format
Click here to enter text.
Click here to enter text.
Click here to enter text.

(5 points per article, maximum 15 points)

5. List if you have served as a reviewer, editor or on an editorial board for JHPN or JPM.

Publication and Role / Start/End Date
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(1 point per term, maximum 4 points)

6. List any services as an author (chapter or book), or editor/reviewer for HPNA publications, including electronic media (other than JHPN or JPM). (List in AMA Format)

Publication and Role
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.

(2 point per instance, maximum 8 points)

7. List participation as faculty at an HPNA educational offering, e.g., Annual Assembly, ELNEC Train-the-Trainer, Clinical Practice Forum, e-Learning, Consultation Hours at Clinical Practice Forum or Annual Assembly.

Title / Meeting / Month/Year
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.

(4 points per presentation, maximum 8 points)

8. List certification from Hospice and Palliative Credentialing Center.

Certification / Years Held
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(5 points per certification, maximum 10 points)

9. List your service as a National Board Member of HPNA, HPCC, or HPNF.

(Move your cursor to Check appropriate box(s) then use the TAB Key to move to the “Years of Term”)

HPNA Board of Directors / Years of Term: Click here to enter text.
Click here to enter text.
HPCC Board of Directors / Years of Term: Click here to enter text.
Click here to enter text.
HPNF Board of Directors / Years of Term: Click here to enter text.
Click here to enter text.

(2 points per year, maximum 12 points)

10. List your service as a committee chair, task force chair, or officer of HPNA, HPCC or HPNF board of directors.

HPNA Specific Position / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
HPCC Specific Position / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
HPNF Specific Position / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(2 points per year in office, maximum 12 points)

11. Service to HPNA, HPCC, or HPNF in a non-board leadership role (Chair of an Exam Development Committee, Review Committee, Chapter Executive Board, SIG Chair or Co-Chair, Award Review Committee, local chapter service).

Committee / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(2 points per year, maximum 12 points)

12. List if you were a recipient of an award given by HPNA, HPCC or HPNF

Award / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(4 points per award, maximum 12 points)

Section II

Academic Training and CEs

(Use the TAB Key to move from block to block, use ENTER/RETURN when filling in the block if needed)

13. List degrees and any completed fellowships attained:

Degree / Institution / Date Completed
MSN / Click here to enter text. / Click here to enter a date.
MS / Click here to enter text. / Click here to enter a date.
MA / Click here to enter text. / Click here to enter a date.
MBA / Click here to enter text. / Click here to enter a date.
MPH / Click here to enter text. / Click here to enter a date.
PhD / Click here to enter text. / Click here to enter a date.
JD / Click here to enter text. / Click here to enter a date.
Other / Click here to enter text. / Click here to enter a date.
Fellowship / Click here to enter text. / Click here to enter a date.

(5 points per degree, maximum 10 points)

14. List other HPNA/HPCC/HPNF board or non-board activities you were involved in that furthered the mission of HPNA (e.g. writing/reviewing position statements or educational products exhibiting, promoting the work of HPNA/HPCC/HPNF by disseminating brochures at state and local conferences, fundraising activities).

Activity / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(2 points per activity, maximum 6 points)

15. List any national sponsored CE activities in which you have participated (National ELNEC, NHPCO, CAPC, etc.)

Activity / Date
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter a date.

(1 point per activity, maximum 3 points)

Section III

Publishing and Research in Palliative Care

(Use the TAB Key to move from block to block, use ENTER/RETURN when filling in the block if needed)

16. List abstracts presented as posters or papers at non-HPNA national conferences or meetings.

Title / Meeting / Month/Year
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.

(3 points per presentation, maximum 6 points)

17. List research grants received.

Title / Granting Agency / Month/Year / Grant Amount
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

(5 points per grant, maximum 10 points)

18. List articles related to palliative care you have published in peer-reviewed journals other than JHPN or JPM.

List Articles in AMA Format
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.

(1 point per article, maximum 4 points)

19. List if you have served as an editor or reviewer, or on an editorial board for a medical or nursing journal other than JHPN or JPM.

Publication and Role / Start/End Date
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(1 point per publication, maximum 2 points)

20. List books, chapters, videos, websites, electronic media, or monographs you have authored, coauthored, or edited (non-HPNA product).

List Titles in AMA Format
Click here to enter text.
Click here to enter text.
Click here to enter text.

(10 points per activity, maximum 30 points)

Section IV

Service Through Teaching

(Use the TAB Key to move from block to block, use carriage returns when filling in the block if needed)

21. List participation as faculty at a non-HPNA national conference, e.g., NHPCO, CAPC, etc.

Title / Meeting / Month/Year
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.

(3 points per presentation, maximum 6 points)

22. List any service as a preceptor of nursing students at any level.

Student Academic Level / Nursing School / Date
Click here to enter text. / Click here to enter text. / Click here to enter date.
Click here to enter text. / Click here to enter text. / Click here to enter date.
Click here to enter text. / Click here to enter text. / Click here to enter date.
Click here to enter text. / Click here to enter text. / Click here to enter date.

(10 points per preceptorship, maximum 40 points)

23. Describe any volunteer mentoring opportunities (nurse practitioner, clinical nurse specialist, visiting nurse clinician, shadowing nurse visits.).

Description of Activity / Year
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.

(1 point per activity, maximum 10 points)

24. List participation as faculty in a non-HPNA educational event related to hospice and palliative care which meets criteria for award of continuing education credit (e.g., local or regional educational program).