FALL 2017 PEER EVALUATOR AVAILABILITY FORM1

FALL 2017PEER EVALUATOR AVAILABILITY FORM

SECTION I – GENERAL INFORMATION

First / Last / Credentials
Position/Job Title
NursingEducation Unit/Department
Governing Organization/Agency
CONTACT INFORMATION -Provide both work and home information and select a preferred mailing address
Work Address
Home Address
WORK INFORMATION
Address
City / State / Zip Code
BusinessEmail
Office Number / Fax Number / Mobile Number
HOME INFORMATION
Address
City / State / Zip Code
PersonalEmail
Home Number / Fax Number / Mobile Number
EMERGENCY CONTACT INFORMATION
Contact Name: / Contact Telephone Number(s):
TRAVEL PREFERENCES
Which airport do you primarily use for traveling? (Please provide airport name, state, and distance in miles.)
Do you have another airport option(s)? (Please provide airport name, state, and distance in miles.)

SECTION II - AVAILABILITY

FALL2017 SITE VISIT DATES (Please select allavailable dates)
Below is a list of all available site visit dates for the Fall 2017 visit cycle. Please select alldate options for which you would like to be considered. Visits are typically three daysplus one travel day. When planning, please take this into consideration. If you are willing to be assigned to two (2)or more visits this Fall, please indicate below.
Assignments will be made immediately upon receipt of the forms.Please respond no later than Friday February 17, 2017 as assignments are made on a first come first serve bases once all information is received.
If you are no longer available to serve as a Peer Evaluator, retired, or planning to retire in the near future, we would appreciate you notifying us . Please note changes made to ACEN Policy #2 expanding the eligibility and period of time to serve as a peer evaluator at
(Please select all applicable options)
Week of September 18, 2017
Week of September 25, 2017
Week of October 2, 2017
Week of October 9, 2017 / Week of October 16, 2017
Week of October 23, 2017
Not Available
Are you available for a second visit? / Yes No
Are you available for a weekend visit?
Are you available to serve on a special purpose visit; for example,Focused Visit? (Dates not represented above) / Yes No
Yes No
How many total visits have you completed? / 0 1 2 3-5 6-10 10+
[For Site Visit Team Chairs]
Of the total visits completed, how many visits have you completed asaTeam Chair?
/
0 1 2 3+
If you have not recently updated your CV/Résumé on file at the ACEN office, please email the electronic file in MS Word or PDF format as an attachment to or by fax to (404) 975-5020.

FALL 2017 PEER EVALUATOR AVAILABILITY FORM1

SECTION III – PROFESSIONAL EXPERIENCE

If you are a peer evaluator in an educator role, please complete Section III.a(p. 3)

If you are a peer evaluator in a clinician role, please complete Section III.b(p. 4)

If you qualify for both areas, please complete both sections.

Section III.a – NURSEEDUCATOR SITE VISIT TEAM ROLE
Types of nursing education programs in which you teach or have taught within the last 18 months.(Check all that apply)
Doctoral
Advanced Practice
Master’s
Baccalaureate
RN-Completion
Associate
Diploma
Practical
Types and characteristics of teaching institutions in which you have taught within the last five (5) years.
(Check all that apply)
Doctoral Degree - Research Focused University
Master's Degree - Focused College or University
Baccalaureate Degree - Focused College or University
Associate Degree - Focused College
Medical Centers
Health Profession Schools
Hospital Based
Vocational/Technical
Characteristics of the institution noted above.
(Check all that apply)
Public
Private
Religious
Free Standing/Single Purpose
For-Profit
Non-Profit
NURSING PROGRAM INFORMATION
Total number of students in your governing organization
Total number of students in your nursing education unit
(all program types that apply)
Clinical Doctorate
Master's
Baccalaureate
Associate
Diploma
Practical
Nursing education programs at your governing organization
(Check all that apply)
Clinical Doctorate
Master's
Post-Master’s Certificate
Baccalaureate (Generic)
Baccalaureate (RN-to-BSN Completion)
Associate (Generic)
Associate (1+1)
Associate (LPN-to-ADN Completion)
Diploma
Practical
DISTANCE EDUCATION
Do you have experience in distance education?
Types of distance education experience.
(check all that apply)
Teaching
Instructional Design/Curriculum Development
Accreditation Review of Distance Education Programs
Administration of Nursing Programs with Distance Education Components / Yes No
Yes No
Yes No
Yes No
Yes No
Section III.b – CLINICIAN SITE VISIT TEAM ROLE
Types of nursing clinicians whom you work with.
(check all that apply)
Advanced Practice Nurses
Baccalaureate Prepared Nurses
Associate Prepared Nurses
Diploma Prepared Nurses
Practical Nurses
Practice settings in which you are practicing/have practiced
(check all that apply)
Medical Center
Community Hospital
Acute Care
Long Term Care
Ambulatory Care
Public Health
Home Care
Industry
Private Practice
Group Practice
School Health
Other (Please specify)
ADVANCED PRACTICE CERTIFICATION
Please provide certification number and dates for all that apply.
Certification / Certification # / Dates
Acute Care Nurse Practitioner
Adult Nurse Practitioner
Family Nurse Practitioner
Gerontological Nurse Practitioner
Pediatric Nurse Practitioner
School Nurse Practitioner
Community Health Clinical Specialist
Gerontological Clinical Specialist
Medical-Surgical Clinical Specialist
Psychiatric and Mental Health Clinical Specialist - Adult
Psychiatric and Mental Health Clinical Specialist - Child and Adolescent
Nursing Administration
Nursing Administration - Advanced
Other (Please specify)

SECTION IV – ADDITIONAL INFORMATION

LANGUAGES
Spanish: Yes No / Speak Read Write
Other: / Speak Read Write
Do you have any physical limitations that may require accommodations or special consideration while you are on a visit? / Yes No
If yes, please explain so your needs may be met.
Notes/Comments and Feedback to ACEN staff

Please send completed Fall 2017Peer Evaluator Availability Form to the ACENby Friday, February 17, 2017.